Form Number/Rev # TGMS Modification Sub-Permit CFM-00008-F1 R3 Requestor Information Requestor: Phone #: Company: Work Sponsor: Bldg./ Location: CNSE Contact Information Emergency Phone # (518) 437-8600 TGMS: Ray Michael – 320-7946 EHS: Jerry Quint – 320-2403 Facilities: Pat O’Dea 437-8817 (Office) 281-7487 (Cell) TGMS: Justin Metzger – 320-5965 TGMS: Anthony Criscione – 944-1109 EHS: Bob Segura - 437-8627 (Office) 470-6882 (Cell) EHS: Jennifer Trodden – 225-8307 TGMS: Dustin Murphy – 795-7326 Work Information Work Summary: AAC’s Affected: Duration of Work: Possible Alarms: Detailed Description of Work Activities: (Include Specific Devices, Programming Details and Systems Affected) Precautions: Do Not Write Below This Line – FOR SUNY USE ONLY – Do Not Write Below This Line Additional Conditions / Concerns System Owner Authorization DCN09471 EHS Approval: Bob Segura or Jennifer Trodden TGMS Approval: Ray Michael Initials: Printed copies are considered uncontrolled. Verify revision prior to use. CNSE Confidential When Completed Initials: Page 1 of 1

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