Temporary System Removal Request Form

TEMPORARY SYSTEM REMOVAL REQUEST FORM

Requestor and System Identification

WHEREAS (Recitals)

WHEREAS, Requestor Name: operates, maintains, or controls the system identified above; and

WHEREAS, Requestor has determined that temporary removal of the system is required for maintenance, relocation, testing, or emergency work; and

WHEREAS, Approving Authority / Approver Name: is authorized to approve the temporary removal under the terms set forth in this form.

Scope of Work

Describe the specific work to be performed, the extent of removal, and any conditions or limitations. Include steps for safe removal, handling of sensitive components, and reinstallation requirements.

Operational Impact and Safeguards

Will the removal affect normal operations? Yes No

Is a full shutdown required? Yes No

Has backup been completed and verified? Yes No

Scheduling and Removal Dates

Requested Removal Start Date:   Estimated Reinstallation Date:   Estimated Duration (days):

Approvals and Authorizations

Approver Name:   Department/Title:

Approval required prior to removal: Yes No

Payment Terms

Agreed fee for removal and reinstallation: $   Payment schedule:

Late payment fee:   Billing contact:

Term and Termination

Effective Start Date:   Expected Term End Date:

Either party may terminate this removal authorization for cause upon written notice delivered at least days prior to the intended termination. Termination does not relieve the terminating party of obligations accrued prior to termination, including payment for completed work and costs for restitution.

Liability, Indemnity, and Safety

Requestor and Contractor shall comply with all applicable safety regulations and site access rules. Requestor acknowledges that removal and off-site transport may expose equipment to risk; Contractor shall exercise commercially reasonable care. Each party agrees to indemnify and hold the other harmless from claims arising out of its gross negligence or willful misconduct in connection with the removal.

Confidentiality

Both parties agree that any nonpublic technical, operational, or business information disclosed in connection with this removal shall be treated as Confidential Information. Confidential Information shall not be disclosed to third parties except as required by law, and shall be protected with at least the same degree of care as each party uses to protect its own confidential information, but not less than reasonable care.

Governing Law

This authorization and any dispute arising under or in connection with it shall be governed by and construed in accordance with the laws of the State of , without regard to conflict-of-law principles.

Entire Agreement

This form, together with any attachments and written approvals executed by the parties, constitutes the entire agreement between the parties with respect to the temporary removal described herein and supersedes all prior or contemporaneous agreements, understandings, and communications, whether written or oral, relating to the subject matter.

Additional Instructions and Emergency Plan

Acknowledgment and Certification

By submitting this form, the Requestor certifies that the information provided is accurate to the best of their knowledge, that all required backups and safeguards have been taken or scheduled, and that unauthorized removal or relocation of equipment is prohibited. The Requestor further acknowledges responsibility for costs arising from failure to comply with the agreed procedures.

Requestor acknowledges: I acknowledge and certify

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