Form7C (CULT)

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					                                 CULT (Common Use Land Transportation)                                                                                DATE RECEIVED:

TMP LOG NO.: (Official Use Only)                                                                        Project ID No.: (Official Use Only)

                                                       CUSTOMER'S INFORMATION                                                                                      OFFICIAL USE ONLY
POC: Branch of Service/Unit:           (circle one)                                                                                                   OCO
                 Army       Marines      Navy          Airforce      Coast Guard         Nat'l Guard     Reserves        Nat'l Disaster               BASOP
Name:                                                                                                                                                 WEEKEND REQUIRED
Unit:                                                                                                                                                 OVERTIME REQUIRED
Bus.:                                                                                                                                                 HAZMAT (Fuel, Ammo)
Cell.:                                                                                                                                                PERMIT REQUIRED
                                                                                                                                                      HPD ESCORT
                                  CUSTOMER'S REQUEST                                                               (Official Use Only)                SUB-CONTRACTOR
MISSION DATE:                                                MISSION TIME:                              CANCELLED (per customer)                      LEGAL REVIEW REQUIRED
                                                                                                        RESCHEDULED (per customer)                    MIPR REQUIRED
                                                                                                        OPEN (Date/Time)                              HOURS BETWEEN 2200 - 0500
                                                                                                        SHUTTLE (Bus Service)
                                                                                                        VARIOUS (Container / ISU)                     OTHER: ____________________________
    Equipment Support: Pls. indicate amount of equipment required.                                                 COST ANALYSIS (OFFICIAL USE ONLY - MIPR Info / SubContractor Only)
BUS:                                  CAGED TRAILER:

NO. OF PAX:                           LOW BOY:                                                          No. of Drivers: ______________                Regular Business Hrs. ______________
ESCORT:                                       TILT DECK                                                 No. of Hours:     _____________               Overtime Hrs. ______________________
TRACTOR:                                       DETACH                                                   SUBCONTRACTOR
5 TON / BREAD TRK:                    RTCH:                                                                                                           TOTAL COST: $_____________________
REFER TRUCK:                          MEDIVAC BUS:                                                      This is purely an estimate, an actual billable cost may vary. Barn time of 2 hrs. are included.
FUEL TRUCK:                           TRAILER:                                                          Note: Hours performed before and after regular Business hours are considered Overtime.
FORKLIFT:                                     40 Ft.                                                                                    MIPR CONTACT INFORMATION
        6K                                    45 Ft.                                                                           (If MIPR required a DD Form 448 submitted To: )
       12K                                                                                              Attn.: IMPC - HI-RMO, STOP 125
       15K                                                                                              742 Santos Dumont Ave., Bldg. 108 WAAF
       45K                                                                                              Schofield Barracks, Hawaii 96857
                                                                                                        Attn.: Beverly Quiba, (808) 656-1850,
                                                                       FUEL REQUESTS (To be Completed by Customer)
TYPE OF FUEL:                                                AMOUNT OF GALLONS:                         PURPOSE:
DIESEL                                                       _______________________________________    GENERATORS                                    AHA (Defuel, Fuel)
MOGAS                                                        _______________________________________    FUEL CANS
JP8                                                          _______________________________________    BARRELL / DRUMS                               OTHER: ____________________________
DODDAC KEY#: _____________________                                                                      WACKER LIGHTS
                                                                   PICK-UP POINT (Specify exact Location and Building No.)

                                                                  DROP-OFF POINT (Specify exact Location and Building No.)

                                                                                          PURPOSE OF REQUEST

                                                       DESCRIPTION OF EQUIPMENT: (i.e. Dimensions and Weight), if required

DIMENSIONS: [_________________] Length            x [_________________] Width             x [________________] Height              and Weight: [__________________] lbs.
Booking No.:                                                                                            VIN Site No.:

                                                                 CUSTOMER'S RESPONSIBILITY
                        Attention: Any Changes / Rescheduling / Canceling of Mission must be notified within 48 hrs. prior to date of mission.
OFFICE SECTIONS:                                             BUSINESS#                                  FAX#                                                   BUSINESS HOURS OF OPERATION:
CULT Section                                                 (808) 656-9353 / 0725                      (808) 656-0727                                         Monday thru Friday
Administration / Division Chief                              (808) 656-2382 / 656-0290                  (808) 656-1215                                         0800 - 1630 (8:00a.m - 4:30p.m)
DOL / ITO Transportation Div.                                (808) 656-8720 / 2391 / 8721 / 8718        (808) 656-8723
PTA - Big Island                                             (808) 969-2474 or (808) 969-2473           (808) 934-0855                                         AFTER HOURS PLEASE CONTACT:
                                                                                                                                                               OFFICERS ON-CALL
                                                                                                                                                               Phone: (808) 284-0110 / 896-1722 / 284-2156
Signature / Title: ____________________________________________________________________________________________________________________
                                       Responsible Party                       Date:
             Responsible Party: Person in charge of the requested support will be responsible to inform Dispatchers of any changes, rescheduling and/or cancellations.
                                                                                             OFFICIAL USE ONLY
                                                                                                                                                      DATE APPROVED:
                                                                                                APPROVING OFFICIAL
USAG-HI Form 7C (CULT)                                                        This Request Form supersedes all other related forms.                                                        Rev.: 12-APRIL-2010

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