3819P43701A01_c2v1_FY26_TGI.pdf

FOUO

FOUO: Public availability to be determined under 5 USC 552

TASK GROUP INSTRUCTION

AIM REV 20.11.4.0 (OCTOBER 2020)

TGI COMPONENT NAME: TYPE: PHASE: REPEAT: CHANGE:

NO.: SA 88714D DFT AY A 0 2

SHIP/HULL NO.: SHIP/HULL NAME: SYSTEM: PROJ/WO NO: CASREP CAT:

LCC-19 USS BLUE RIDGE 19P

CU PHASE TITLE:

*F/O - S/A 88714D ACCOMPLISH MODIFICATION OF DEAERATING FEED TANK LEVEL CONT SYS

PREPARING ACTIVITY:

PREPARED BY: CODE PHONE DATE

KAZUKI UCHIMURA 233. 809-350-1432 09-APR-2025

APPROVED BY: CODE PHONE DATE

MASAHIRO HOSONO 233 080-9350-1455 09-APR-2025

CONCURRED BY: CODE PHONE DATE

CONCURRED BY: CODE PHONE DATE

CONCURRED BY: CODE PHONE DATE

CONCURRED BY: CODE PHONE DATE

REASON FOR WORK/NEED FOR CHANGE:

Typo miss.

CHANGE INSTRUCTIONS:

CH1: revise QA Form 28. (04/16/2025) CH2: revise paragraph 5.6 (07/11/2025)

SPECIAL REQUIREMENTS:

WORK CERTIFICATION SIGNATURES

COMPLETION OF WORK REVIEW: BADGE NO.: SHOP/CODE: PHONE: DATE:

ACCEPTANCE OF COMPLETED WORK

PHYSICAL INSPECTION PHYSICAL INSPECTION COMPLETED: BADGE NO.: SHOP/CODE: PHONE: DATE:

REQUIRED:☐YES ☒NO

RECORDS REVIEW: BADGE NO.: SHOP/CODE: PHONE: DATE:

TGI NO.: SA 88714D DFT AY A 0

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SHIP: LCC-19 CHG/VER: 2/1

LIST OF EFFECTIVE PAGES

SHT NO. CHG NO. SHT NO. CHG NO. SHT NO. CHG NO. SHT NO. CHG NO. SHT NO. CHG NO.

1-5 QA28

(1)

J1-2 M1-9

QA28

(1-3)

1. SCOPE/PURPOSE

1.1 Title: S/A 88714D, Modification of Deaerating Feed Tank Level Control System; accomplish

1.2 Location of Work:

1.2.1 Fire Room (8-76-0-E)

1.2.2 Engine Room Enclosed Operating Station (6-86-0-E)

1.3 Identification:

1.3.1 Quantity (One EA), Deaerating Feed Tank Level (DFT) Control System, Power Remarks: See 2.3 and 2.6 for details.

1.3.2 Quantity (One EA), DFT Level Control System, Alarm

Remarks: See 2.4 and 2.6 for details

1.3.3 Quantity (One Lot), DFT Level Control Transmitter Piping Remarks: See 2.5 for detail.

1.3.4 Quantity (One Lot), Control Air Tubing for DFT Level Control System Remarks: See 2.9 for detail.

1.3.5 Quantity (One Lot), Dirty Drain Piping

Remarks: See 2.10 for detail.

1.3.6 Quantity (2 EA), Control Air Supply Valves for Positioner Mfr: Various.

Mfr Id: 803-4384536-15B1AF Item No: V1 of 2.9 Size: 1 / 4 inch Type: Union End Globe

1.3.7 Quantity (2 EA), Valve Positioner, Digital for Control Valves (Excess and Make Up Feed Control Valves)

Model: Flowserve 3800

1.4 Security Classification: None.

1.5 Initial Condition:

1.5.1 Potential Asbestos Hazard

1.5.2 Potential Lead Hazard

1.6 Contractor work start date: 7/21/2026

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SHIP: LCC-19 CHG/VER: 2/1

1.7 Contractor work completion date:

2. REFERENCES:

REF.

NO.

DOCUMENT

/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV CHG

NO.

COPY

REQ’D

(Y/N)

SOURCE

DOC

(Y/N)

PARA SEC PG CH

P

1 NSI FY-26 NAVSEA Standard Items - 1 N 2 LI FY-26 Local Standard Items - ORG N

3 DWG 302-

8683965

POWER SYSTEM

MODIFICATIONS DEAERATING

FEED TANK LEVEL CONTROL

SYSTEM

A Y ALL

4 DWG 401-

8683673

ALARM MODIFICATIONS

DEAERATING FEED TANK LEVEL

CONTROL SYSTEM

A Y ALL

5 DWG 208-

8682665

DEAERATING FEED TANK (DFT)

LEVEL CONTROL TRANSMITTER

FIREROOM

A Y ALL

6 PDD 302-

ELM-250099

SUPPLEMENTAL INFO FOR SCD

18714 DFT LEVEL CONTROL

SYSTEM

- Y ALL

7 LAR SRFY-

0240-24

DISCREPANCY OF ELECTRICAL

EQUIPMENTS IN DWG 8683965 &

8683673 FOR S/A 88714D

- Y ALL

8 MIL MIL-

STD-2003

Electric Plant Installation Standard Methods for Surface Ships and Submarines

B N

9 DWG 513-

8683776

CONTROL AIR MODIFICATIONS

DFT LEVEL CONTROL SYSTEM

ROOM (8-76-0-E), L/L, STBD

A Y ALL

10 DWG 514-

8783549

DIRTY DRAIN PIPING REMOVAL

FIRE ROOM

- Y ALL

11 TM 0948-LP-

012-5000

Standard Navy Valves 31 Y SH 4.3-

12 DWG 803-

4384536

Valves, BRZ, 1/4" - 2" Union End Globe, In-Line & ANG, Stop, Stop Check & Needle

N Y ALL

13 TM S9086-

RK-STM-

010/CH-505

Piping System 6 N

3. APPENDICES:

3.1. Appendix “J” TGI Job Summary Information Sheet

3.2. Appendix "M" TGI Material List

3.3. Appendix “D” Deficiency Form

4. GENERAL REQUIREMENTS:

4.1 Not Applicable.

5. PROCEDURE:

5.1 Pump out, clean, and dry the bilge area located in 1.2.1 to free from oil, debris, and other foreign matter.

5.2 Accomplish electrical removals, modifications and installations of the system listed in 1.3.1 and 1.3.2 in accordance with 2.3 through 2.7.

5.2.1 Electrical installations must be in accordance with 2.8.

11/21/2027

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SHIP: LCC-19 CHG/VER: 2/1

5.2.2 Fabricate and install each new label plate in accordance with 2.3 and 2.7.

5.2.3 Accomplish the requirements of 009-12 of 2.1, including Table 2, Column(s) D, Lines One through 7.

5.3 Accomplish the piping work for S/A 88714D listed in 1.3.3 through 1.3.5 in accordance with 2.5, 2.9 and 2.10.

5.3.1 Accomplish the requirements of 009-12 of 2.1, including Table One, Column(s) A, Lines One through 10.

5.3.1.1 Accomplish nondestructive testing in accordance with Line 13 for liquid penetrant testing accomplished to satisfy operational pressure test option for DFT level control transmitter piping listed in 1.3.3.

5.3.2 Accomplish the requirements of 009-71 of 2.1 for hydrostatic test, using feed water at 50 PSIG, for new and disturbed DFT level control transmitter piping listed in 1.3.3.

5.3.2.1 Document shop hydrostatic test results on QA Form 28 Enclosure-01-1.

5.3.3 Accomplish the requirements of 009-71 of 2.1 for hydrostatic test, using clean, fresh water at 203 PSIG, for new and disturbed control air tubing listed in 1.3.4.

5.3.3.1 Document shop hydrostatic test results on QA Form 28 Enclosure-01-2.

5.3.4 Accomplish the requirements of 009-71 of 2.1 for hydrostatic test, using clean, fresh water at 50 PSIG, for new and disturbed dirty drain piping system listed in 1.3.5.

5.3.4.1 Document shop hydrostatic test results on QA Form 28 Enclosure-01-3.

5.3.5 Accomplish flow check of dirty drain piping listed in 1.3.5, using clean, fresh water. Allowable external leakage:

None.

(V)(G) “FLOW CHECK”

5.4 Accomplish a bonnet ring torque check of each new valve listed in 1.3.6 in accordance with Table 4.3-10 of 2.11, and using 2.12 for guidance.

5.4.1 Inspect and tighten each bonnet ring of each new valve.

(V)(G) “TORQUE CHECK”

5.4.1.1 Torque of each bonnet ring of each new valve is 18 to 20 foot pounds.

5.4.2 Accomplish a hydrostatic test of each new valve listed in 1.3.6, using 2.12 for guidance.

5.4.2.1 Hydrostatic test equipment must conform to the requirements in Paragraph 505-11.1.3 of 2.13.

5.4.3 Accomplish a mechanical joint tightness test of each new valve listed in 1.3.6 with stem in the half- open position, using clean fresh water at 150 PSIG (not less than 150 PSIG and not more than 153 PSIG) for a minimum of 3 minutes. Allowable external leakage: None.

(V)(G) “MECHANICAL JOINT TIGHTNESS TEST”

5.4.4 Document a shop hydrostatic test result on QA Form 28, Enclosure-02-1.

5.4.5 After satisfactory completion of each shop test, drain water from each new valve and blow with clean dry air to remove moisture.

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SHIP: LCC-19 CHG/VER: 2/1

5.4.6 Cycle the valve from fully closed to fully open to fully closed 4 times. Allowable binding: None.

(V)(G) “VALVE CYCLING” (V1)

(V)(G) “VALVE CYCLING” (V1)

5.5 Remove existing and install each new valve positioner listed in 1.3.7 in accordance with DETAIL 35-A of 2.5.

5.6 Remove existing and install each new valve listed in 1.3.6 in accordance with DETAIL 12-A (V1) of 2.9.

5.7 Accomplish the requirements of 009-32 of 2.1 for each new and disturbed surface.

5.8 Notes:

5.8.1 Planner: Code 233 K. Uchimura, 080-9350-1432

Planner: Code 231B T. Ashina, 243-4370 Planner: Code 232 H. Matsubayashi, 243-4509 Planner: Code 234 S. Yamashita, 070-7787-2035

5.8.2 Provision of oily/chemical water barge will be coordinated by Project Team.

5.8.3 Work Integration Manager (WIM): Code 333 T. Yaginuma, 080-5419-0598

5.8.4 JCN EXSA-ZBG1 is related to this TGI.

5.9 Government Furnished Material (GFM)

5.9.1 All GFM listed in each S/A drawing will be provided as kitted material.

5.9.2 SRF-JRMC will provide GFM listed in Appendix “M”.

5.10 SRF-JRMC will provide the following service work: (TGI No. 3819P43701S03).

5.10.1 [C740] Crane and crane rigger service.

5.10.2 [X99E] Utility service, electrical.

5.10.3 [X99M] Utilities service, including low pressure air supply, water supply, and steam supply.

5.10.4 [C106.1] Safety inspection for SRF-JRMC employees.

5.10.5 [C106.2] Gas free inspection for SRF-JRMC employees.

5.10.6 [C133] QA inspection for (G) Symbol(s).

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J-1

SHIP: LCC-19 CHG/VER: 2/1

APPENDIX "J"

TGI JOB SUMMARY INFORMATION SHEET

SYSTEM: PLANT NO.: COMPONENT NAME: TYPE: PHASE: REPEAT: CU PH

VERSION:

CASREP

CAT:

SA 88714D DFT AY A 0 1

CU PHASE TITLE:

*F/O - S/A 88714D ACCOMPLISH MODIFICATION OF DEAERATING FEED TANK LEVEL CONT SYS

PRIMARY COMPONENT:

COMPONENT UNIT LIST (FOR ASSEMBLIES):

CONT AIR SPLY V1 V- K-14/15SS1 C- K-14/16SS5 C- K-15SS2 C- K-15SS3

C- K-15SS4 C- K-15SS5 C- K-16SS7 C- K-16SS8 C- DFT DUMP

LVL CONT CT DFT MAKE-UP LVL CONT CT JB K-16SS1 BX K-15SS6 C- K-16SS1

C- K-16SS2 C- K-16SS3 C- K-16SS4 C- K-16SS9 C- K-5PG2

C- K-5PG3 C- DFT COND LVL A/M STA CS DFT INDICATOR GAUGE GA DFT LVL IND &

ALARM ID DFT LVL RADAR XMTR XM POL CTL 8-76-0-E PP DFT SIGHTGLASS DRN PP CNDS

8-76-0-E PP MUFD CONT V34 OP MUFD CONT V34 V- EXCESS FEED CONT V31 OP

EXCESS FEED CONT V31 V- DFT SIGHTGLASS SS CMPT 8-76-0-E MSDFT SIGHTGLASS

COV V-

ATTACHMENT LIST:

1. ENCLOSURE-01 (3819P43701A01-QA28-01_.docx) saved on 16-APR-2025 0000.

2. ENCLOSURE-02 (3819P43701A01-QA28-02_.docx) saved on 16-APR-2025 0000.

ZONE MANAGER: ZONE: COMPARTMENT: LEVEL: FRAME: SIDE:

TAKAHASHI ,YASUHIKO

JO: KO: TOTAL MAN HRS: PLANNING ACCEPTANCE:

3819P43701 A01

TOTAL MAT’L COST TOTAL DURATION:

CU PHASE DESCRIPTION:

The purpose of this TGI is to accomplish modification of deaerating feed tank level control system.

Location of Work:

Fire Room (8-76-0-E) Engine Room Enclosed Operating Station (6-86-0-E)

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

5.1 SFTR, LBR

5.2 ELEC, SFTR, WELD, PNTR, QA, RGRS

5.3 PFTR, RGRS, WELD, IMCH, OMCH, PNTR, INSL, QA

5.4 IMCH, QA

5.5 OMCH

5.6 OMCH

5.7 PNTR, QA

Electrical Work CFM: for banding material, fasteners, insulation tape, plastic bags, rope, and other consumable.

Structure Work CFM: for marine chemist, all paints, thinner, lead analysis cost, firewatch cost, and misc such as electrode, gases, temporary covering, and other consumable.

Machinery Work CFM: for fastener, shim, and MISC such as other consumable.

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J-2

SHIP: LCC-19 CHG/VER: 2/1

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

Piping Work CFM: for firewatch cost, asbestos sampling/ analyze cost for pipe lagging, covering material, argon gas, disposable coverall, plastic bag/sheet, tape, welding rod, gasket, saw blade, paint, thinner, NDT cost and MISC.

Process Funding Document.

Version-1: revise Enclosure-01 and Enclosure-02. C233 M.

Hosono, 4/16/2025, -/-/N

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M-1

SHIP: LCC-19 CHG/VER: 2/1

APPENDIX “M”

TGI MATERIAL LIST

SYSTEM: PLANT NO.: COMPONENT NAME: TYPE: PHASE: REPEAT: CU PH

VERSION:

CASREP

CAT:

SA 88714D DFT AY A 0 1

CU PHASE TITLE:

*F/O - S/A 88714D ACCOMPLISH MODIFICATION OF DEAERATING FEED TANK LEVEL CONT SYS

MATERIAL REFERENCES

REF

NO.

DOCUMENT/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV

1 8682665 2 8683776 3 7171 4 8683965 5 8683673 6 208-8682665 A 7 514-8783549 8 302-8683965 A

JOB ORDER: KEY OP:

3819P43701 A01

MATERIAL LIST

ITEM

NO.

PC

NO.

REF

NO.

M

C DESCRIPTION

STOCK

NUMBER

GENERIC

MATL

TYPE LVL QA

HAZ

MAT

DOC

NO.

QTY

REQD/

UNIT

QTY

USED/

UNIT

001 F2 1 M BOSS, BOSS, 1/2"IPS X 1-1/4" ~

2-1/2"RUN, SW, 90/10, 400PSI.

DWG: 208-8682665, ITEM NO:

F2

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 LL4464631 NA 4 N 90927416 2/EA

002 F13 1 M RUBBER SHEET SOLID, DWG:

208-8682665, ITEM NO: F13.

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5330 014905051 NA 4 N 90470138 2/SH

NOTES:

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M-2

SHIP: LCC-19 CHG/VER: 2/1

MATERIAL LIST

ITEM

NO.

PC

NO.

REF

NO.

M

C DESCRIPTION

STOCK

NUMBER

GENERIC

MATL

TYPE LVL QA

HAZ

MAT

DOC

NO.

QTY

REQD/

UNIT

QTY

USED/

UNIT

003 F14 1 M CAP, 2"IPS, SW, CAP, 2"IPS,

SW, 90/10, 400PSI.

DO NOT CROSS NSN 4730-01-

551-5271 SMIC X3

DWG: 208-8682665, ITEM NO:

F14

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 LL4462607 NA 4 N 90927415 1/EA

004 F17 1 M FLANGE, FLANGE, NAVY,

BLIND, 1/2"IPS, CNA 70-30,

150PSI, DWG: 803-6983512,

FIG 13-D ITEM 121.

DWG: 208-8682665, ITEM NO:

F17

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 LL6958848 NA 4 N 90927406 1/EA

005 F22 1 M BAR, ROUND,

BAR,METAL,ROUND, 5"OD,

CU/NI, 90/10, MIL-C-15726

COMP C70600, TEMP: 060

SOFT 80.40 LBS/FT.

DWG: 208-8682665, ITEM NO:

F22

ALASKAN P/N: 405438

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 9510 LL9307687 NA 4 N 90477427 1/FT

006 V1 2 M VALVE, NEEDLE, VALVE,

1/4"IPS, IN-LINE NEEDLE TYPE,

400 PSIG, UNION END,

NONMETALLIC DISK SEATING

SURFACE,

NON-ASBESTOS, BRONZE,

NITRILE.

DWG: 513-8683776, ITEM NO:

V1

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4820 LL9307675 NA 4 N 90437430 2/EA

007 F4 2 M NIPPLE,TUBE, DWG: 513-

8683776, ITEM NO: F4

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 003693338 NA 4 N 90430066 2/EA

008 9 3 M NUT,SELF-LOCKING,HE, DWG:

445-7171, ITEM NO: 9

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5310 004838792 NA 4 N 90770025 1/HD

009 11 3 M SCREW,CAP,SOCKET HE,

DWG: 445-7171, ITEM NO: 11

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5305 016291493 QX NA 4 N 90770027 1/EA

010 12 3 M WASHER,FLAT, DWG: 445-

7171, ITEM NO: 12

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5310 001670820 NA 4 N 90770028 1/HD

011 3 M WASHER,LOCK, DWG: 445-

7171, ITEM NO: 13

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5310 008329712 NA 4 N 90770029 5/EA

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M-3

SHIP: LCC-19 CHG/VER: 2/1

MATERIAL LIST

ITEM

NO.

PC

NO.

REF

NO.

M

C DESCRIPTION

STOCK

NUMBER

GENERIC

MATL

TYPE LVL QA

HAZ

MAT

DOC

NO.

QTY

REQD/

UNIT

QTY

USED/

UNIT

012 F1 1 M FLANGE, FLANGE

C,3/4"IPS,BLIND, BLIND, 150

PSI, CARBON STEEL, ASTM A-

105,150 LB,ASTM A-105,ASME

B16.5, RAISED FACE.

DWG: 208-8682665, ITEM NO:

F1

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 LL9307688 NA 4 N 90927405 1/EA

013 1 4 M AUTOMATION CONTROL,

AUTOMATION CONTROL,

FAIRMOUNT AUTOMATION

CONTROLLER, MODEL FAC-

2100 NRP,CONT,MULTI-LOOP

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 6110 LL9301481 NA 4 N 90397409 1/EA

014 2 4 M CONNECTOR,PLUG,ELEC,

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5935 010769450 NA 4 N 90390058 1/EA

015 3 4 M CONNECTOR,PLUG,ELEC,

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5935 011579553 NA 4 N 90390061 1/EA

016 4 4 M CONNECTOR,PLUG,ELEC,

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5935 010775856 NA 4 N 90390066 1/EA

017 5 4 M CONNECTOR,PLUG,ELEC,

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5935 011150215 NA 4 N 90390068 1/EA

018 6 4 M BACKSHELL,ELECTRICA,

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5935 011729918 NA 4 N 90390071 1/EA

019 7 4 M BACKSHELL,ELECTRICA,

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5935 013235804 NA 4 N 90390072 3/EA

020 15 4 M CABLE,SPECIAL PURPO, DWG:

302-8683965, ITEM NO: 15

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

9B 6145 012027769 NA 4 N 90390081 120/FT

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M-4

SHIP: LCC-19 CHG/VER: 2/1

MATERIAL LIST

ITEM

NO.

PC

NO.

REF

NO.

M

C DESCRIPTION

STOCK

NUMBER

GENERIC

MATL

TYPE LVL QA

HAZ

MAT

DOC

NO.

QTY

REQD/

UNIT

QTY

USED/

UNIT

021 F16 1 M UNION TA, UNION TAILPIECE

ASSY, SIZE: 1/2"IPS, SOCKET

WELDING,CU-NI 90/10,400

PSI,COPPER-NICKEL

TAILPIECE WITH BRONZE

NUT,SEAL TYPE : NITRILE O-

RING WITH RETAINER

RING.803-7063850.

DWG: 208-8682665, ITEM NO:

F16

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 LL4699742 NA 4 N 90507413 4/EA

022 F5 2 M UNION TA, UNION TAILPIECE

ASSY, SIZE: 1/4"IPS, SOCKET

WELDING, CNA 90-10, 400 PSI,

COPPER-NICKEL TAILPIECE

WITH BRONZE NUT, SEAL

TYPE : NITRILE O-RING WITH

RETAINER RING.

DWG: 513-8683776, ITEM NO:

F5

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 LL4601697 NA 4 N 90437447 4/EA

023 F7 2 M PIPE HANGER, PIPE HANGER,

3/8"OD, TY 35B, STEEL, 2-3/4"

STUD LENGTH.

DWG: 513-8683776, ITEM NO:

F7

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 LL4658203 NA 4 N 90437426 4/EA

024 4 3 M STANDOFF HEX, STANDOFF

HEX, FEMALE THREADED 10-

32UNF SCREW SIZE, 1-1/2"LG

STAINLESS STEEL 18-8,

HEX SIZE: 1/4", PARTIALLY

THREADED, MINIMUM THREAD

LENGTH 1/2", ASTM A582.

DWG: 445-7171, ITEM NO: 4

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5305 LL4647606 NA 4 N 90777404 2/EA

025 5 3 M NUT,SELF-LOCKING,HE, DWG:

445-7171, ITEM NO: 5

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5310 008775797 NA 4 N 90770021 1/HD

026 8 3 M WASHER,FLAT, DWG: 445-

7171, ITEM NO: 8

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5310 008098546 NA 4 N 90770024 1/MX

027 10 3 M BOLT,MACHINE, DWG: 445-

7171, ITEM NO: 10

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5306 002258499 NA 4 N 90770026 1/HD

028 14 3 M NUT, HEX, NUT, HEX 18-8

STAINLESS STEEL,3/8"-24UNF-

2B.

DWG: 445-7171, ITEM NO: 14

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

9B 5310 LL4647610 NA 4 N 90777405 1/EA

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M-5

SHIP: LCC-19 CHG/VER: 2/1

MATERIAL LIST

ITEM

NO.

PC

NO.

REF

NO.

M

C DESCRIPTION

STOCK

NUMBER

GENERIC

MATL

TYPE LVL QA

HAZ

MAT

DOC

NO.

QTY

REQD/

UNIT

QTY

USED/

UNIT

029 16 3 M ROD END , ROD END CRES,

BALL BORE : 0.250", BALL

WIDTH : 0.375", HEAD TO

CENTER : 1.312", HEAD DIA :

0.750", 1/4-28UNF-3B, RIGHT

HAND FEMALE

DWG: 445-7171, ITEM NO: 16

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 3040 LL4647617 NA 4 N 90777406 1/EA

030 17 3 M ROD END , ROD END CRES,

BALL BORE : 0.250", BALL

WIDTH : 0.375", HEAD TO

CENTER : 1.312", HEAD DIA :

0.750", 1/4-28UNF-3B, LEFT

HAND FEMALE

DWG: 445-7171, ITEM NO: 17

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 3040 LL4647618 NA 4 N 90777407 1/EA

031 18 3 M NUT, JAM NUT, 1/4"-28UNF-2B,

RH, MATL: CRES, FOR SW-4E,

ROD END,

DWG: 445-7171, ITEM NO: 18

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5310 LL9307791 NA 4 N 90787429 1/EA

032 19 3 M NUT, JAM NUT, 1/4"-28UNF-2B,

LH, MATL: CRES, FOR ROD

END, 1/4"-28UNF, LH FEMALE,

P/N: SG-4E,

DWG: 445-7171, ITEM NO: 19

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5310 LL9307792 NA 4 N 90787430 1/EA

033 10 4 M CONVERTER,SIGNAL DA,

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5895 016252900 NA 4 N 90390074 1/EA

034 11 4 M FUSE,CARTRIDGE, DWG: 302-

8683965, ITEM NO: 11

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5920 002808342 NA 4 N 90390076 1/EA

035 13 4 M CABLE,POWER,ELECTRI,

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 6145 012027750 NA 4 N 90390077 60/FT

036 14 4 M CABLE,POWER,ELECTRI,

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

9B 6145 012026973 NA 4 N 90390079 200/FT

FOUO

M-6

SHIP: LCC-19 CHG/VER: 2/1

MATERIAL LIST

ITEM

NO.

PC

NO.

REF

NO.

M

C DESCRIPTION

STOCK

NUMBER

GENERIC

MATL

TYPE LVL QA

HAZ

MAT

DOC

NO.

QTY

REQD/

UNIT

QTY

USED/

UNIT

037 F6 2 M ADAPTER, FLAGG STANLEY

P/N: 6863-040, PREMIER P/N:

99161040, W&O P/N:

640063.040

ADAPTER, 1/4"IPS, FEMALE

PIPE THREAD X SOCKET

WELDING, CNA 90-10.

DWG: 513-8683776, ITEM NO:

F6

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 LL4920998 NA 4 N 90437429 4/EA

038 V1 1 M VALVE,GATE, DWG: 208-

8682665, ITEM NO: V1

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4820 011382982 NA 4 N 90470132 2/EA

039 F7 1 M STUD, STUD, 1/2"-13UNC-3A X

4"LG, GR-400. MONEL,MIL-DTL-

1222, TYPE-IV, GR-400,STUD

BOLT, CONTINUOUS THREAD.

DO NOT CROSS NSN: 5307-01-

307-0377 (LEVEL 1 MATERIAL).

DWG: 208-8682665, ITEM NO:

F7

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5307 LL9307689 NA 4 N 90477429 24/EA

040 F8 1 M WASHER,LOCK, DWG: 208-

8682665, ITEM NO: F8

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5310 001872429 NA 4 N 90470134 1/HD

041 F9 1 M NUT,PLAIN,HEXAGON, DWG:

208-8682665, ITEM NO: F9

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5310 015921568 NA 4 N 90470135 48/EA

042 F10 1 M SCREW, SCREW, HEX CAP,

5/8"-11UNC-2A X 3"LG, CRES

316,MIL-DTL-1222 TYPE I

,ANNEALED.

DWG: 208-8682665, ITEM NO:

F10

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5305 LL9307690 NA 4 N 90477430 4/EA

043 F11 1 M NUT,PLAIN,HEXAGON, DWG:

208-8682665, ITEM NO: F11

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5310 013722670 NA 4 N 90470136 4/EA

044 1 3 M SCREW, SCREW, SOCKET,

FLAT HEAD, M6 X 12MML,

ALLOY STEEL, BLACK OXIDE,

DIN 7991, CLASS 10.9, 1 PCK =

100EA.

DWG: 445-7171, ITEM NO: 1

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

9B 5305 LL6987472 NA 4 N 91317455 1/PG

FOUO

M-7

SHIP: LCC-19 CHG/VER: 2/1

MATERIAL LIST

ITEM

NO.

PC

NO.

REF

NO.

M

C DESCRIPTION

STOCK

NUMBER

GENERIC

MATL

TYPE LVL QA

HAZ

MAT

DOC

NO.

QTY

REQD/

UNIT

QTY

USED/

UNIT

045 2 3 M SCREW, SCREW, SOCKET,

FLAT HEAD, COUNTERSUNK

82 DEGREES, #10-32UNF X

3/8" LENGTH,, 18-8 STAINLESS

STEEL, 50EA/PG.

DWG: 445-7171, ITEM NO: 2

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5305 LL9307793 NA 4 N 91317456

100/EA

046 6 3 M SCREW,CAP,HEXAGON H,

DWG: 445-7171, ITEM NO: 6

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5305 001484275 NA 4 N 90770022 1/EA

047 7 3 M WASHER,FLAT, DWG: 445-

7171, ITEM NO: 7

ORDERED FOR C282

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5310 008238804 NA 4 N 90770023 1/HD

048 8 4 M ENCLOSURE, CONTROL

PANEL ENCLOSURE, 10" X 8" X

6", ON/OFF START/STOP,

GREY.

MODEL NUIMBER:

1414N4PHI6, CONTINUOUS

HINGED TYPE, NEMA TYPE 12.

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5975 LL9307665 NA 4 N 90397437 1/EA

049 9 4 M TERMINAL BOARD, DWG: 302-

8683965, ITEM NO: 9

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5940 009836053 NA 4 N 90390073 1/EA

050 P1 2 M TUBE,METALLIC, DWG: 513-

8683776, ITEM NO: P1

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4710 002774027 NA 4 N 90430063 20/FT

051 F2 2 M ADAPTER, ADAPTER,

STRAIGHT, MALE PIPE 3/8" OD

X 1/4" NPT, NSN 4730-00-580-

2070, QDR: N62758-18-0023

DWG: 513-8683776, ITEM NO:

F2

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 LL9307679 NA 4 N 90457422 8/EA

052 P1 1 M TUBE,METALLIC, DWG: 208-

8682665, ITEM NO: P1

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4710 002774655 NA 4 N 90470130 5/FT

053 P2 1 M TUBE,METALLIC, DWG: 208-

8682665, ITEM NO: P2

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

3B 4710 002898006 NA 4 N 90470131 10/FT

FOUO

M-8

SHIP: LCC-19 CHG/VER: 2/1

MATERIAL LIST

ITEM

NO.

PC

NO.

REF

NO.

M

C DESCRIPTION

STOCK

NUMBER

GENERIC

MATL

TYPE LVL QA

HAZ

MAT

DOC

NO.

QTY

REQD/

UNIT

QTY

USED/

UNIT

054 10 4 M CONVERTER,

CONVERTER,SIGNAL, ONE, 4-

20MA INPUT, TWO 4-20MA

OUTPUTS, MULTI-CHANNEL

DESIGN, 2000VAC ISOLATION,

UNIVERSAL DC POWER 10.8

TO 26.4 VDC, HIGH DENSITY

DIN RAIL MOUNTING,

DWG: 302-8683965, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5895 LL9307693 NA 4 N 90477433 1/EA

055 F3 1 M ELBOW,PIPE, DWG: 208-

8682665, ITEM NO: F3

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 016051394 NA 4 N 90470133 2/EA

056 F12 1 M FLANGE, FLANGE, SIZE: 2"

IPS, SW, FLAT FACE, 150PSI,

MATL: CNA 90-10, , REF DWG:

803-6983512, FIGURE 39-E,

ITEM. 229.

DWG: 208-8682665, ITEM NO:

F12

ORDERED FOR X56P

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 4730 LL4462151 NA 4 N 90927414 1/EA

057 1 5 M CONNECTOR,PLUG,ELEC,

DWG: 401-8683673, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5935 010769452 NA 4 N 90390050 1/EA

058 2 5 M BACKSHELL,ELECTRICA,

DWG: 401-8683673, ITEM NO:

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 5935 011729912 NA 4 N 90390053 1/EA

059 3 5 M CABLE,SPECIAL PURPO, DWG:

401-8683673, ITEM NO: 3

ORDERED FOR X51IC

ORIG: Y.TSUCHIYA.

PHONE:243-4488

9B 6145 012027772 NA 4 N 90390055 120/FT

060 F20 6 M POSITIONER,VALVE, ORDER

FOR KTR

ORIG: C-226 Y. TSUCHIYA 080-

9350-1436

3B 4820 016928990 NA 4 N 42775205 2/EA

061 P1 7 M TUBE,MET, ORDER FOR KTR

ORIG: C-226 Y. TSUCHIYA 080-

9350-1436

9B 4710 002774657 NA 4 N 42775032 3/FT

062 F1 7 M COUPLING, ORDER FOR KTR

ORIG: C-226 Y. TSUCHIYA 080-

9350-1436

9B 4730 014635857 NA 4 N 42775029 2/EA

063 12 8 M LABEL PLATE, LABEL PLATE,

MANUFACTURE LABEL PLATE

IAW ATTACHED DETAILS.

THE ORIGINATOR WILL

PROVIDE THE LABEL PLATE

DETAILS.

ORDER FOR KTR

ORIG: C-226 Y. TSUCHIYA 080-

9350-1436

9B 9905 LL1111111 NA 4 N 50077604 1/GP

FOUO

M-9

SHIP: LCC-19 CHG/VER: 2/1

MATERIAL LIST

ITEM

NO.

PC

NO.

REF

NO.

M

C DESCRIPTION

STOCK

NUMBER

GENERIC

MATL

TYPE LVL QA

HAZ

MAT

DOC

NO.

QTY

REQD/

UNIT

QTY

USED/

UNIT

064 M RAIL,ASSEMBLY, C233 K.

UCHIMURA, 080-9350-1432

ORDERED FOR KTR

9B 5940 991194382 NA 4 N 50945206 1/EA

065 M PAD, TAPPED ROUND, PAD,

TAPPED ROUND, 1/4"-20UNC-

2B X 1"LG, STEEL, CARBON,

AISI-1020, CENTERED,

CONCENTRIC INTERNAL

THREAD THRU HOLE 5/8" OD,

FINISH: PLAIN.

BIW CATALOG NO.53204-155

C233 K. UCHIMURA, 080-9350-

ORDERED FOR KTR

9B 5340 LL9003506 NA 4 N 50947621 4/EA

066 M TRANSMITTER,RADAR, C233

K. UCHIMURA, 080-9350-1432

ORDERED FOR KTR

3B 5840 015422685 PP NA 4 N 50945226 1/EA

067 M BACKSHELL,ELECTRICA, C233

K. UCHIMURA, 080-9350-1432

ORDERED FOR KTR

9B 5935 014868492 NA 4 N 50945109 1/EA

068 M BACKSHELL,ELECTRICA, C233

K. UCHIMURA, 080-9350-1432

ORDERED FOR KTR

9B 5935 011595803 NA 4 N 50935601 3/EA

069 M BACKSHELL,ELECTRICA, C233

K. UCHIMURA, 080-9350-1432

ORDERED FOR KTR

9B 5935 011716669 NA 4 N 50945106 1/EA

FOUO: Public availability to be determined under 5 USC 552 SHEET_____OF_____

☐ NUCLEAR APPENDIX "D"

DEFICIENCY FORM

☐ NON-NUCLEAR

1. SHIP/HULL NO.: 2a. DL or DR No.

(Circle One)

2b. REVISION: 3a. COMPONENT NAME: 3b. TYPE: 3c. PHASE: 3d. REPEAT:

LCC-19 SA 88714D DFT AY A 0

4a. ICN: 4b. KEY OP: 5. LOC SPACE/LVL: FRAME: P/S/C: 6. CAUSED BY:

3819P43701 A01

7. DESCRIPTION:

8. ORIGINATOR: NAME: BADGE: SHOP/CODE: DATE: PHONE NO.:

9. CORRECTIVE ACTION:

10. EVALUATOR: NAME: BADGE: SHOP/CODE: DATE: PHONE NO.:

FOR NON-NUCLEAR USE ONLY

11. RFD/RFW REQ’D ☐ LAR REQ'D ☐

ILS MOD REQ’D ☐

SRD/PLAN REV REQ'D ☐

DWG NO.: _____________________ S/A NO.: ___________________

12. ISOLATION SIGN: BADGE: SHOP/CODE: DATE: PHONE NO.:

SATISFACTORY:

13. SUBSAFE OQE RECORD? SIGN: BADGE: SHOP/CODE: DATE: PHONE NO.

YES ☐ NO ☐

14. CORRECTIVE ACTION SIGN: BADGE: SHOP/CODE: DATE: PHONE NO.

COMPLETE:

15. INSPECTION REQ’D? INSPECTION COMPLETE/SIGN: BADGE: SHOP/CODE: DATE: PHONE NO.

_________:YES ☐ NO ☐

16. RECORDS REVIEW SIGN: BADGE: SHOP/CODE: DATE: PHONE NO.

COMPLETE (DR ONLY)

DL’s ISSUED

(DR ONLY)

FOUO: Public availability to be determined under 5 USC 552 SHEET_____OF_____

☐ NUCLEAR Deficiency Form Continuation Sheet ☐ NON-NUCLEAR

1. SHIP/HULL NO.: 2a. DL or DR No.

(Circle One) 2b. REVISION: 3a. COMPONENT NAME: 3b. TYPE: 3c. PHASE: 3d. REPEAT:

LCC-19 SA 88714D DFT AY A 0

COMUSFLTFORCOMINST 4790.3 REV D CHG 4

24 SEP 2024

SHOP TEST RECORD Page 1 of 1

QA FORM 28 Planning must fill in blocks identified by a prior to issuing

1. SHIP HULL NO. 2. JCN 3. LWC/SHOP 4. CWP/REC SER NO. 5. SYSTEM/COMPONENT/ROTATABLE POOL SER NO.

USS BLUE RIDGE LCC-19 EXSA-ZBG1 KTR N/A DFT Level Control Transmitter Piping

6. REFERENCES: TEST REF (E.G., MS, TECH MAN) & OTHER REFS (E.G., VLV DWG) 7. TEST GAGE RANGE /INSTRUMENT USED SERIAL NO. CAL DUE DATE 8. RELIEF VLV SET POINT

A. DWG: 208-8682665 Rev. A

B. S9086-RK-STM-010/CH-505 Rev.6

C.

D.

9. TEST REQUIREMENTS & RESULTS

TEST TYPE KEY H = STRENGTH AND POROSITY/ELEVATED PRESSURE TEST J = MECHANICAL JOINT TIGHTNESS ST = SEAT TIGHTNESS OP = OPERATIONAL O = OTHER

(SPECIFY): ______________________

TE

ST

T Y

PE

(S

EE

K

EY

) PARAGRAPH

DESCRIBING

VALVE POSITION

AND POINT OF

ENTRY

REF

LTR

GAGE

USED

(LTR

FROM

BLK 7)

REQUIRED

MEDIUM

USED

PRESSURE

ACTUAL

MINIMUM

DURATION

ALLOWED

LEAKAGE

ACTUAL

LEAKAGE SAT/UNSAT SIGNATURE, BADGE NO. & DATE

H 5.3.2 A,B Feed Water 50 PSIG 30 minutes None

10. REMARKS. (CRAFTSMAN/QAI SUBMIT A DF TO RESOLVE UNSAT DATA)

11. QA INSPECTOR/SHOP SUPERVISOR SIGNATURE/BADGE NO. (RECORD

REVIEWED FOR FINAL ACCEPTANCE)

DATE 12. QAS SIGNATURE/BADGE NO. (RECORD HAS BEEN REVIEWED FOR

COMPLETENESS)

DATE

3819P43701A01 ENCLOSURE-01-1 TOTAL 3

SHOP TEST RECORD Page 1 of 1

QA FORM 28 Planning must fill in blocks identified by a prior to issuing

1. SHIP HULL NO. 2. JCN 3. LWC/SHOP 4. CWP/REC SER NO. 5. SYSTEM/COMPONENT/ROTATABLE POOL SER NO.

USS BLUE RIDGE LCC-19 EXSA-ZBG1 KTR N/A Control Air Tubing

6. REFERENCES: TEST REF (E.G., MS, TECH MAN) & OTHER REFS (E.G., VLV DWG) 7. TEST GAGE RANGE /INSTRUMENT USED SERIAL NO. CAL DUE DATE 8. RELIEF VLV SET POINT

A. DWG: 513-8683776 Rev. A

B. S9086-RK-STM-010/CH-505 Rev.6

C.

D.

9. TEST REQUIREMENTS & RESULTS

TEST TYPE KEY H = STRENGTH AND POROSITY/ELEVATED PRESSURE TEST J = MECHANICAL JOINT TIGHTNESS ST = SEAT TIGHTNESS OP = OPERATIONAL O = OTHER

(SPECIFY): ______________________

TE

ST

T

K

EY

) PARAGRAPH

DESCRIBING

VALVE POSITION

GAGE

USED

(LTR

ACTUAL

LEAKAGE SAT/UNSAT SIGNATURE, BADGE NO. & DATE

H 5.3.3 A,B Clean Fresh Water

203 PSIG 30 minutes None

10. REMARKS. (CRAFTSMAN/QAI SUBMIT A DF TO RESOLVE UNSAT DATA)

11. QA INSPECTOR/SHOP SUPERVISOR SIGNATURE/BADGE NO. (RECORD

REVIEWED FOR FINAL ACCEPTANCE)

DATE 12. QAS SIGNATURE/BADGE NO. (RECORD HAS BEEN REVIEWED FOR

COMPLETENESS)

3819P43701A01 ENCLOSURE-01-2 TOTAL 3

SHOP TEST RECORD Page 1 of 1

QA FORM 28 Planning must fill in blocks identified by a prior to issuing

1. SHIP HULL NO. 2. JCN 3. LWC/SHOP 4. CWP/REC SER NO. 5. SYSTEM/COMPONENT/ROTATABLE POOL SER NO.

USS BLUE RIDGE LCC-19 EXSA-ZBG1 KTR N/A Dirty Drain Piping

6. REFERENCES: TEST REF (E.G., MS, TECH MAN) & OTHER REFS (E.G., VLV DWG) 7. TEST GAGE RANGE /INSTRUMENT USED SERIAL NO. CAL DUE DATE 8. RELIEF VLV SET POINT

A. DWG: 514-8785349 Rev. “-”

B. S9086-RK-STM-010/CH-505 Rev.6

C.

D.

9. TEST REQUIREMENTS & RESULTS

TEST TYPE KEY H = STRENGTH AND POROSITY/ELEVATED PRESSURE TEST J = MECHANICAL JOINT TIGHTNESS ST = SEAT TIGHTNESS OP = OPERATIONAL O = OTHER

(SPECIFY): ______________________

TE

ST

T

K

EY

) PARAGRAPH

DESCRIBING

VALVE POSITION

GAGE

USED

(LTR

ACTUAL

LEAKAGE SAT/UNSAT SIGNATURE, BADGE NO. & DATE

H 5.3.4 A,B Clean Fresh Water

50 PSIG 30 minutes None

10. REMARKS. (CRAFTSMAN/QAI SUBMIT A DF TO RESOLVE UNSAT DATA)

11. QA INSPECTOR/SHOP SUPERVISOR SIGNATURE/BADGE NO. (RECORD

REVIEWED FOR FINAL ACCEPTANCE)

DATE 12. QAS SIGNATURE/BADGE NO. (RECORD HAS BEEN REVIEWED FOR

COMPLETENESS)

3819P43701A01 ENCLOSURE-01-3 TOTAL 3

SHOP TEST RECORD Page 1 of 1 QA FORM 28 Planning must fill in blocks identified by a prior to issuing

1. SHIP HULL NO. 2. JCN 3. LWC/SHOP 4. CWP/REC SER NO. 5. SYSTEM/COMPONENT/ROTATABLE POOL SER NO.

USS BLUE RIDGE LCC-19 EXSA-ZBG1 KTR N/A Control Air supply valves for positioner (V1)

6. REFERENCES: TEST REF (E.G., MS, TECH MAN) & OTHER REFS (E.G., VLV DWG) 7. TEST GAGE RANGE /INSTRUMENT USED SERIAL NO. CAL DUE DATE 8. RELIEF VLV SET POINT

A. DWG: 5138683776 Rev. A

B. S9086-RK-STM-010/CH-505 Rev.6

C.

D.

9. TEST REQUIREMENTS & RESULTS

TEST TYPE KEY H = STRENGTH AND POROSITY/ELEVATED PRESSURE TEST J = MECHANICAL JOINT TIGHTNESS ST = SEAT TIGHTNESS OP = OPERATIONAL O = OTHER

(SPECIFY): ______________________

TE

ST

T

K

EY

) PARAGRAPH

DESCRIBING

VALVE POSITION

GAGE

USED

(LTR

ACTUAL

LEAKAGE SAT/UNSAT SIGNATURE, BADGE NO. & DATE

J PARA 5.4.3 A, B

Clean fresh water

150 psig 3 minutes None

10. REMARKS. (CRAFTSMAN/QAI SUBMIT A DF TO RESOLVE UNSAT DATA)

11. QA INSPECTOR/SHOP SUPERVISOR SIGNATURE/BADGE NO. (RECORD

REVIEWED FOR FINAL ACCEPTANCE)

DATE 12. QAS SIGNATURE/BADGE NO. (RECORD HAS BEEN REVIEWED FOR

COMPLETENESS)

3819P43701A01 ENCLOSURE-02-1 TOTAL 1