FM-9130 v03 Issue Date: 11-16-2016 Page 2 of 2

IE Facility Name: / Request Submittal Date:
ATC Substation:
Test Start Date: / Start Time:
Test Completion Date: / Completion Time:
Requestor Name: / Phone#:
Requestor Fax#: / E-mail:
Person-In-Charge: / Phone#:
Work in a substation interconnected to ATC may carry risks to ATC-owned equipment (such as inadvertent contact, clearance requirements, proximity to underground cables, etc.). Contact the ATC System Control Operator when entering the interconnected substation to inform ATC of testing activities regardless of the need for this form.
Please see directions on page 2 and answer all questions below to determine if this form needs to be submitted.
1.  Will an IE owned protective scheme that provides protection of ATC-owned equipment be disabled or removed from service while the ATC-owned equipment remains energized? / Yes No
If the answer to Question 1 is YES, please complete and submit ATC Protective Relay or Communication Channel Testing request via TOA or if necessary Form FM-9120
2.  Does any equipment to be worked on trip ATC-owned equipment (including transfer trip systems)? If YES, complete questions (a) and (b) below. / Yes No
a.  Will any IE-owned relay trip output not be isolated by an open test switch? / Yes No
b.  Will any IE-owned relay trip output to ATC-owned equipment not be isolated by an open test switch? / Yes No
3.  Will any IE-owned equipment to be worked on include connections other than trip circuits to ATC-owned equipment (e.g. differential current circuits, control circuits to breakers/circuit switchers, etc.)? / Yes No
4.  Will connections to ATC-owned equipment be disturbed or modified during testing (e.g. shorting/grounding CT wiring, lifting control circuit wiring, etc.)? / Yes No
If this form must be submitted to ATC, please email this form to the ATC Outage Coordinator at a minimum of 10 business days prior to the equipment testing. IE should not initiate testing without ATC approval.

Scope of Work (if any answer to Questions 2 thru 4 is YES, provide details of work below and identify ATC transmission elements that could be impacted as a result of a testing error):

To be completed by ATC

Approver notes:

______, Outage Coordinator


DIRECTIONS FOR FILLING OUT FORM:

1.  This form must be reviewed whenever an Interconnected Entity will be testing equipment in the following types of substations:

a.  All substations where generation is connected to the transmission system.

b.  All distribution substations with protection schemes that trip ATC-owned circuit breakers, circuit switchers or lockout relays, or distribution substations that have equipment connected to ATC-owned bus differential schemes.

2.  This form does not need to be submitted to ATC if any of the following conditions are true:

a.  Whenever an ATC Outage request has been submitted via the ATC Transmission Outage Application (TOA) for the ATC equipment that could be accidentally tripped, or

b.  Whenever an ATC Protective Relay or Communication Channel Testing request has been submitted via TOA that mitigates the risk of inadvertent operation of ATC equipment that could be accidentally tripped, or

c.  Only Question 1 is answered “Yes” on the FM-9130.

3.  This form must be submitted to ATC if none of the criteria in part 2 above are met and the following is true:

a.  For a positive response (YES) to FM-9130 Question 2, 2a, 2b, 3 or 4.

4.  Notification of intent to perform equipment testing at an Interconnected Entity station should be submitted as follows:

a.  An ATC Interconnected Entity Equipment Testing Form should be submitted a minimum of 10 Business days in advance of the planned testing and-or outage date.

b.  Emergent Work Activities: submittal times may be waived to allow for expedited repair. The ATC Outage Coordinator will evaluate system conditions and coordinate work with transmission system scheduled outages.

c.  Emergency repair and Trouble-Shooting: the Interconnected Entity individual responsible for the work should communicate directly with the ATC System Control Operator to coordinate these activities.

5.  This form can be used for small scopes of work, such as testing single elements (e.g. a single relay or circuit breaker), or larger scopes of work, such as whole substations. Enough information needs to be provided to determine any risks associated with equipment testing at the substation interconnected with ATC.

6.  Please contact ATC if you have any questions, or if additional coordination (e.g. a walk-down) with ATC would be beneficial in advance of submitting this form.

7.  ATC will review the IE equipment testing schedule and confirm that the testing plans do not conflict with the planned transmission system configuration. ATC will also review the IE equipment testing schedule the day of testing and confirm that the testing plans do not conflict with the actual transmission system configuration prior to the testing. The Person In-Charge must call the ATC System Control Operator on the day of the planned work prior to testing.

CAUTION: Any paper or filed copy of this document should be verified against the record version on an ATC on-line system.