SAGINAW (WLIC 160B) DS FQ2 ECE 2600.pdf

USCGC SAGINAW (WLIC 803)

SPECIFICATION FOR DOCKSIDE REPAIRS

FY2026

Developed By: Erik C Elasik

(Draft-00, 10 July 2025)

USCGC SAGINAW (WLIC-160B) DOCKSIDE AVAILABILITY FY2026

ii (Draft-00)

TABLE OF CONTENTS

Revisions Record...............................................................................................................................iii Consolidated List of References .........................................................................................................iv Consolidated List of Government-furnished Property ...........................................................................vi Consolidated List of Critical Inspection Items ....................................................................................vii Principal Characteristics...................................................................................................................viii General Requirements WORK ITEM 1: Tanks, Potable Water, Clean and Inspect WORK ITEM 2: Tanks, Ballast, Clean and Inspect WORK ITEM 3: Voids, Accessible, Clean and Inspect WORK ITEM 4: Tanks, Dirty Oil and Waste, Clean and Inspect WORK ITEM 5: Main Diesel Engine, MDE, Exhaust Piping, Commercial Clean WORK ITEM 6: Ship Service Diesel Generator, SSDG, Exhaust Piping, Commercial Clean WORK ITEM 7: Boiler Exhaust Stack Uptakes, Commercial Clean WORK ITEM 8: Hull Fittings, Weight Handling Rigging Hardware, Inspect and Test WORK ITEM 9: Crossdeck Winch, Inspect & Service WORK ITEM 10: Capstan, Inspect and Service WORK ITEM 11: Spud Winches, Inspect & Service WORK ITEM 12: Boat Davit, Inspect & Service WORK ITEM 13: Sewage Holding Tanks, Clean and Inspect WORK ITEM 14: Grey Water Piping, Clean and Flush WORK ITEM 15: Sewage Piping, Clean and Flush iii (Draft-00)

REVISIONS RECORD

This page is used to record specification revisions, which may have occurred subsequent to a Revision 0 (Rev -0) package. Information listed is intended to provide contractors and field unit personnel a means to ensure all the current specification revision pages are present when reviewing or utilizing this specification package.

DATE REV# WORK

ITEM#

CHANGES MADE

NOTE : All work item and paragraph numbers listed above for a given revision correspond to same numbers in the previous revision. This revised specification is self-contained with all of the above listed changes incorporated.

iv (Draft-00)

CONSOLIDATED LIST OF REFERENCES

The below-listed documents form a part of this specification to the extent specified herein. Approval/publication dates or revision dates/numbers are also identified, to ensure that same document versions are used at the time of specification writing and during contract execution.

All Coast guard drawings, technical publications, and standard specifications will be provided to contractors by the Coast Guard at an appropriate time, or upon request, free of charge. Other Government documents may be accessed – free of charge – from links located on the SFLC website. Commercial sites provide access to their respective documents.

COAST GUARD DRAWINGS

Coast Guard Drawing 160 WLIC 1107-1, Rev L, Dk House Eng Casing & Stacks

Coast Guard Drawing 160 WLIC 4105-3, Rev H, Arrgt Eng & Boiler Exhaust

Coast Guard Drawing 160B WLIC 103-003, Rev-, Booklet of General Plans

Coast Guard Drawing 160B WLIC 103-003, Rev-, Booklet of General Plans

Coast Guard Drawing 160B WLIC 4808-1, Rev-, Pollution & Drainage Sys

Coast Guard Drawing 160B-WLIC 103-3, Rev -, Booklet of General Plans

Coast Guard Drawing 160B-WLIC 4105-3, Rev H, Eng & Boiler Exhaust

Coast Guard Drawing 160-WLIC 8201-7, Rev A, Boat Davit and Pedestal Assembly

Coast Guard Drawing FL 1204-3, Rev A, Welded Padeyes & Links

Coast Guard Fleet Drawing FL-1112-18, Rev -, HU40 Series Spud Winch Foundation

COAST GUARD PUBLICATIONS

Coast Guard Commandant Instruction (COMDTINST) M10360.3, Jun 2006, Coatings and Colors Manual

Coast Guard Technical Publication (TP) 2056, Manufacturer's Instruction Book-SWBS Group(s) 313-665

Coast Guard Technical Publication (TP) 4417, SWBS 582, Section A, Jan 2011, Warping Capstan

Coast Guard Technical Publication (TP) 4958, Section A, Amendment 1; Mar 2011, Utility Air Winch Model HU-40 Series

Fire Prevention and Response

Surface Forces Logistics Center Standard Specification 0000 (SFLC Std Spec 0000), 2014, General Requirements

Surface Forces Logistics Center Standard Specification 0000 (SFLC Std Spec 0000), 2020, General Requirements

Surface Forces Logistics Center Standard Specification 0000 (SFLC Std Spec 0000), 2022, General Requirements

Surface Forces Logistics Center Standard Specification 0000 (SFLC Std Spec 0000), Latest Version, General Requirements

Surface Forces Logistics Center Standard Specification 0740 (SFLC Std Spec 0740), 2020, Welding and Allied Processes

Surface Forces Logistics Center Standard Specification 0740 (SFLC Std Spec 0740), 2022, Welding and Allied Processes v (Draft-00)

Surface Forces Logistics Center Standard Specification 0740 (SFLC Std Spec 0740), Latest Version, Welding and Allied Processes

Surface Forces Logistics Center Standard Specification 5000 (SFLC Std Spec 5000), 2014, Auxiliary Machine Systems

Surface Forces Logistics Center Standard Specification 5000 (SFLC Std Spec 5000), 2020, Auxiliary Machine Systems

Surface Forces Logistics Center Standard Specification 5550 (SFLC Std Spec 5550), Latest Version, Surface Forces Logistics Center Standard Specification 6310 (SFLC Std Spec 6310), 2020, Requirements for Preservation of Ship Structures

Surface Forces Logistics Center Standard Specification 6310 (SFLC Std Spec 6310), 2022, Requirements for Preservation of Ship Structures

Surface Forces Logistics Center Standard Specification 6310 (SFLC Std Spec 6310), Latest Version, Requirements for Preservation of Ship Structures

Surface Forces Logistics Center Standard Specification 8636 (SFLC Std Spec 8636), 2022, Temporary Hull Accesses

OTHER REFERENCES

American National Standards Institute/American Water Works Association (ANSI/AWWA) C652, 2011, Disinfection of Water-Storage Facilities

American National Standards Institute/NSF International (ANSI/NSF) 61, 2015, Drinking Water System Components - Health Effects

ASTM International (ASTM) D1330, 2010, Standard Specification for Rubber Sheet Gaskets

ASTM International (ASTM) D1330, 2015, Standard Specification for Rubber Sheet Gaskets

Code of Federal Regulations (CFR) Title 29, Part 1915, 2014, Occupational Safety and Health Standards for Shipyard Employment

Code of Federal Regulations (CFR) Title 29, Part 1915, 2022, Occupational Safety and Health Standards for Shipyard Employment

Code of Federal Regulations (CFR) Title 29, Part 1915, Occupational Safety and Health Standards for Shipyard Employment

NAVSEA Technical Publication T9074-AD-GIB-010/1688, (TP 1688), July 2012, Requirements for Fabrication, Welding, and Inspection of Submarine Structure

Society of Automotive Engineers (SAE) Aerospace Material Specification (AMS) C6183, 2019, Cork and Rubber Composition Sheet; For Aromatic Fuel and Oil Resistant Gaskets vi (Draft-00)

CONSOLIDATED LIST OF GOVERNMENT-FURNISHED PROPERTY

The following is a list of property, which the Government will furnish. This list supersedes any other material obligations indicated or implied by referenced drawings.

This section is not applicable to this package.

vii (Draft-00)

CONSOLIDATED LIST OF CRITICAL INSPECTION ITEMS

The following is a list of work items, which contain Critical Inspection reports, which the Contractor must complete within the first 25% of the availability contract period (see SFLC Std Spec 0000, paragraph 3.2.6.5 (Inspection report particulars)):

Work Item

Title

2 Tanks, Ballast, Clean and Inspect

10 Capstan, Inspect and Service

12 Boat Davit, Inspect & Service viii (Draft-00)

PRINCIPAL CHARACTERISTICS

160' WLIC (B-CLASS), INLAND CONSTRUCTION TENDER

PHYSICAL

Length overall 160' 10"

Depth (main deck at side to baseline) 10' 0"

Maximum beam 30' 0"

Height of highest fixed projection 40’ 0” (above keel)

Height of highest projection with antenna mast extended

59’ 0” (above keel)

Frame spacing 1' 0"

Full load draft 4' 7-1/2” LCF Draft

Full load displacement 474.73 Long Tons (Fresh water)

Shore tie voltage requirements N/A

HULL

Hull material Steel

MACHINERY

Number of propellers 2

Number of blades per propeller 4

Diameter of propeller 48"

Pitch 44" fixed

RPM 475

Shaft diameter N/A

TANK CAPACITIES

Fuel tanks

Fresh water tanks

Lube oil

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00000_0824_FLT

REC_00000_FLT_Commercial Project @ CG Facility (0121)

General Requirements

1. SCOPE

1.1 Intent. This standard specification invokes general requirements for conducting vessel repairs performed by commercial contractors at a Coast Guard facility for Coast Guard vessels.

1.2 Term interchangeability. The terms 'Contractor', 'CG Yard', 'NAVSTA EVERETT', 'shipyard', 'Base', and 'Coast Guard Industrial' are used interchangeably in this specification. Where the primary service provider is Coast Guard personnel, references to contractor and other noted descriptors within this specification or within drawings, publications, SFLC Standard Specifications or other commercial and military references are deemed the same as prime service provider.

2. REFERENCES

COAST GUARD DRAWINGS

None

COAST GUARD PUBLICATIONS

Coast Guard Commandant Instruction (COMDTINST) M10360.3 (series), Coatings and Color Manual

Surface Forces Logistics Center Standard Specification 0000 (SFLC Std Spec 0000), Latest Version, General Requirements

Surface Forces Logistics Center Standard Specification 0740 (SFLC Std Spec 0740), Latest Version, Welding and Allied Processes

Surface Forces Logistics Center Standard Specification 5550 (SFLC Std Spec 5550), Latest Version, Fire Prevention and Response

Surface Forces Logistics Center Standard Specification 6310 (SFLC Std Spec 6310), Latest Version, Requirements for Preservation of Ship Structures

OTHER REFERENCES

Code of Federal Regulations (CFR) Title 29, Part 1915, Occupational Safety and Health Standards for Shipyard Employment

NAVSEA Technical Publication T9074-AD-GIB-010/1688, (TP 1688), July 2012, Requirements for Fabrication, Welding, and Inspection of Submarine Structure

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3. REQUIREMENTS

3.1 General. The Contractor must conform to all requirements specified in SFLC Std Spec 0000 and in this item, as applicable, during the performance of this availability. The requirements in this WI applies to all work under the scope of this contract, whether explicitly stated in all following work items or not, and to all other work subsequently authorized by changes, modifications, or extensions to the contract.

3.1.1 The Contractor must conform to all requirements specified in SFLC Std Spec 5550 and in the Fire Protection and Response work item, as applicable, during the performance of this availability.

3.1.1.1 Fire Safety Plan submission. The Contractor must submit a copy of the CFR 1915, Subpart P, Fire Safety Plan with the Contractor’s bid when work will be conducted in a Contractor–owned facility. Include any MOA(s) with local firefighting facilities.

3.1.1.2 Fire Plan submission. The Contractor must submit a copy of the developed availability specific fire plan, as requested in the Fire Protection and Response work item, seven (7) days before the Arrival Conference.

NOTE

NAVSEA drawings listed will be available FOR INSPECTION ONLY from the Coast Guard Port Engineer post-award. SFLC will not redistribute NAVSEA documents.

Contractors can apply to NAVSEA headquarters directly for copies.

3.2 Contractor-provided fire watch personnel. The Contractor must provide fire watch personnel and equipment.

3.3 Preservation requirements. The Contractor must accomplish all preservation tasks, including touch-ups, in accordance with SFLC Std Spec 6310.

3.3.1 Brand name approval. Ensure that all contractor-furnished coatings are in accordance with SFLC Std Spec 6310, Appendix C (Authorized Coatings for Use on Cutters and Boats).

3.3.2 Coating colors and system color schemes. The Contractor must obtain a written KO authorization to deviate from any coatings required in SFLC Std Spec 6310 Appendix C before work.

3.3.3 In-process quality control measures. The Contractor must abide by all the safety, preservation, and quality control requirements specified in SFLC Std Spec 0000, paragraph 3.2.4.2 (In-process QC measures for “critical-coated surfaces”).

3.3.3.1 Quality control requirements. The Contractor must abide by the following when performing preservation related inspections. The following measurements must be randomly spaced throughout for the purposes of providing a representation of the entire prepared or coated surface.

3.3.3.1.1 Surface profile measurements. One surface profile measurement must be taken for every 200 square feet for the first 1000 square feet; for each additional 500 square feet or less, one profile measurement must be taken.

Profile measurements must be taken in accordance with SFLC Std Spec 6310, paragraph 3.1.8.3 (Surface profile measurements). A “measurement” for surface profile is defined as follows:

• ASTM D4417, Method B: One profile measurement is the average (mean) of 10 individual readings.

• ASTM D4417, Method C: One profile measurement is the average (mean) of 2 individual readings.

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3.3.3.1.2 Soluble salt conductivity measurements. 5 conductivity measurements must be taken every 1000 square feet. For submerged (immersed) applications conductivity measurements must not exceed 30 microsiemens/cm.

For non-submerged (non-immersed) applications conductivity measurements must not exceed 70 microsiemens/cm. If a conductivity check fails, clean the surface in accordance with SFLC Std Spec 6310, paragraph 3.1.8.5 (Soluble salt removal).

3.3.3.1.3 Coating thickness measurements. Three area measurements must be taken for the first 1000 square feet;

for each additional 1000 square feet, perform an additional area measurement. A “measurement” for coating thickness is defined as follows:

• SSPC-PA 2 defines an area measurement as 5 separate spot measurements randomly spaced throughout a 100 square foot area.

• SSPC-PA 2 defines a spot measurement as 3 gage readings and each new gage reading the probe must be moved to a new location within a 1.5-inch diameter circle defining the spot.

3.4 Welding and brazing requirements. The Contractor must perform all welding and allied processes, and NDE in accordance with SFLC Std Spec 0740.

3.4.1 HY-130 material substitution. The Contractor must be aware that HY-130 steel plating is no longer commercially available. For the purpose of performing flight deck repairs on US Coast Guard WMEC-270 “B- Class” cutters, Weldox 900 steel plating has been approved as a replacement for HY-130. Due to the similarity in material properties and weldability of HY-130 and Weldox 900, all welding procedures and welder qualifications for welding Weldox 900 must be the same as those outlined in NAVSEA TP 1688 as applicable for welding HY- 130.

3.4.2 Standard spec modification. For any welding involving HY-130 on the flight deck of WMEC-270 “B-Class” cutters, perform all welding and allied processes, and non-destructive evaluation (NDE) in accordance with NAVSEA TP 1688. The Contractor must be aware that the welding requirements specified in this document take precedence over paragraph 3.3.6 of SFLC Standard Spec 0000 for the purpose of welding involving HY-130.

3.4.3 Approval to weld HY-130. To obtain Coast Guard approval to weld on HY-130 steel for WMEC-270 “B- Class” cutters, the Contractor must provide written Performance Qualification Records (PQR’s) for each process to be used. The PQR’s must be approved by one of the regulatory agencies affirming that the WPS meets the welding requirements of NAVSEA TP 1688. In addition, the Contractor must ensure that all subcontractors, prior to performing welding operations, have qualified procedures by meeting all the requirements set forth in this document.

NOTE

NAVSEA approval is NOT required for welding procedures submitted but the procedures must be reviewed and shown to satisfy the requirements set forth in NAVSEA TP 1688, by a welding regulatory agency. The requirements for welding

Weldox 900 are considered the same as those for welding HY-130.

3.5 Environmental protection requirements. The Contractor must adhere to the following environmental protection requirements in accordance with the SFLC Stand Spec 0000:

3.5.1 USCG facilities. The Contractor must provide and maintain environmental protection as defined in SFLC Std Spec 0000 Appendix B, Requirements for Environmental Protection at USCG Facilities, during the performance of this availability. Contractor must plan for and provide environmental protective measures to control pollution that develops during normal practice, as well as plan for and provide environmental protective measures required to correct conditions that develop during the project. Contractor must comply with applicable

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Federal, state, and local laws, codes, ordinances, and regulations in their entirety. Any reference to a specific portion of a Federal, state, or local law, code, ordinance, or regulation in this or any other item must not be construed to mean that relief is provided from any other sections of the law, code, ordinance, or regulation.

APM: For availabilities to be conducted at Coast Guard facilities, the Contractor must be provided the USCG Activity Generator Status for the Coast Guard Facility.

Provide the Generator Status code in paragraph 3.5.1.1, and other applicable environmental permits in paragraph 3.5.1.2 below.

Ensure the CG Base or Sector Environmental POC for this is actively engaged in the early planning for this availability to ensure the Facility can accommodate the planned work.

3.5.1.1 USCG Generator status. The activity Generator Status for the Coast Guard Facility is__________ (IPF

NOLA).

3.5.1.2 Plans and permits. The CG Facility has unit specific permits including the following:

• Spill Prevention Control and Countermeasures (SPCC) Plan: Unit has a SPCC Plan which requires certain unit-specific procedures be followed for the storage, inspection, and transfer of petroleum products in containers 55 gallons or greater.

• National Pollutant Discharge Elimination System (NPDES) Storm Water (SW) Permit: Unit has an NPDES SW permit which requires unit-specific procedures be followed for the storage and inspection of equipment and materials which may contribute contaminants to storm water discharges.

• Air Emission Permit: Unit has an Air Emission Permit which requires unit-specific procedures be followed for the emissions of VOCs and hazardous air pollutants.

3.5.2 Test and procedures. The Contractor is required to promptly conduct tests and procedures for the purpose of assessing whether operations are in compliance with applicable Environmental Laws. Analytical work must be done by qualified laboratories; and where required by law, the laboratories must be certified.

3.5.3 Regulatory notifications. The Contractor is responsible for all regulatory notification requirements in accordance with Federal, State and local regulations. In cases where the Coast Guard must also provide public notification, such as storm water permitting, the Contractor must coordinate with the Contracting Officer or COR, and if work is being performed at a USCG Facility, the local Facility Engineer or Engineering Officer. The Contractor must submit copies of all regulatory notifications to the Contracting Officer and the local Facility Engineer or Engineering Officer prior to commencement of work activities. Regulatory notifications must be provided for including but not limited to demolition, renovation, National Pollutant Discharge Elimination System (NPDES) defined site work, and remediation of controlled substances such as asbestos, hazardous waste, and lead paint.

3.5.4 Environmental manager. The Contractor must appoint in writing an Environmental Manager for the project, who is responsible for coordinating Contractor compliance with Federal, State, local, and station environmental requirements. The Environmental Manager must ensure compliance with Hazardous Waste Program requirements, including hazardous waste handling, storage, manifesting, and disposal; implement the Contractors’ Environmental Management Plan; ensure that all environmental permits are obtained, maintained, and closed out;

ensure compliance with Storm Water Program Management requirements; ensure compliance with Hazardous Materials including storage, handling, and reporting requirements; as well as coordinate any remediation of regulated substances such as lead, asbestos, and polychlorinated biphenyl (PCB). This may be a collateral position; however the individual must be trained to accomplish the following duties; ensure waste segregation and storage compatibility requirements are met; inspect and manage Satellite Accumulation areas; ensure only

5 (Draft-00) authorized personnel add wastes to containers; ensure all Contractor personnel are trained in 40 CFR requirements and individual position requirements; coordinate removal of waste containers; and maintain the Environmental Records binder and required documentation, including environmental permits compliance and close -out.

3.5.5 HW disposal. Contractor must comply with SFLC Std Spec 0000 Appendix B, Requirements For Environmental Protection At USCG Facilities for HW disposal, and ensure that waste removals are conducted during normal business hours (0800-1600) on Monday through Friday (excluding holidays).

3.5.6 Additional Requirements. The Contractor must be aware of the following:

3.5.6.1 No Contractor or Subcontractor must have the authority to sign a Hazardous Waste Manifest using the Coast Guard facility’s EPA Generator ID Number or remove contract generated hazardous waste from the Coast Guard facility without COR or KO-approval.

3.5.6.2 Local environmental regulations at the Government facilities may be more stringent. As with all environmental regulations, the Contractor must prepare for and comply with local and state regulations.

3.5.6.3 Coast Guard facilities do not maintain Facilities Response Plans (FRPs) per 33 CFR 154. Contractor must furnish the FRP when required for over-the-water liquids transfers to and from vessels, and is required for oil/fuel transfers to/from vessels for 250 barrels (10,500 gallons) or more.

3.6 Local Policy. The Contractor must refer to site (e.g., Base) Regulations and Instructions for details regarding local policies (e.g., crane services, parking, or facility usage).

3.7 SFLC Standard Specification approved changes. Approved updates to the 2022 SFLC Standard Specifications will appear here.

3.7.1 SFLC Standard Specification 5550: Replace paragraph 3.11.3 to state, “Material supporting imminent work shall be brought on the cutter and stored where the work is being performed. Material that appreciably contributes to fire load shall be removed at the end of each work shift when personnel are not present. Trash, debris, and packaging materials shall be promptly removed from the vessel at the end of each work shift and not allowed to accumulate.” Advance the paragraph numbering of the Fire Prevention and Safety Inspection form to 3.11.4.

4. NOTES

4.1 QA inspection forms. QA inspection forms (QA-1 thru QA-5), required in SFLC Std Spec 6310 to be completed and submitted during preservation of “critical-coated surfaces”, are provided at the end of this document.

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QA-1 - QUALITY ASSURANCE INSPECTION FORM

(PRESERVATION CHECKLIST)

VESSEL NAME HULL # WORK ITEM

WORK ITEM TITLE

LOCATION OF WORK (INCL. FRAME #’S) AREA (SQFT)

CHECKPOINT 1 – COATING SYSTEM COMPLIANCE

Ensure all coatings are in compliance with SFLC Std Spec 6310, Appendix C.

CHECKPOINT 2 - PAINT STORAGE

Ensure all coatings are kept at a temperature of 65 to 85°F at all times, unless otherwise specified by the coating mfg.

CHECKPOINT 3 - AMBIENT CONDITIONS

Ensure surface and surrounding temperatures are each between 50 and 90°F for water-containing coatings, and 35 and 95°F for other coatings, unless otherwise specified by the coating manufacturer(s).

Ensure maximum relative humidity (RH) is as follows, from surface preparations through final curing of topcoat: 50% for tanks, voids, and vent plenum; and 85% for all other areas, unless otherwise specified by manufacturer(s).

Ensure surface temperature is at least 5°F above the dew point, unless otherwise specified by the coating mfg.

CHECKPOINT 4 - PRE-SURFACE PREPARATION

Remove surface contaminants (soluble salts, loose rust, mud, and marine growth) with low pressure fresh water wash down (maximum 5,000 psi). If oil and grease are present, perform solvent cleaning, as per SSPC SP-1.

Verify equipment setup, blast media, and surface preparation methods match designated test coupon.

CHECKPOINT 5 - SURFACE PREPARATION

Verify environmental conditions (see CHECKPOINT 3).

Ensure cleanliness of prepared surface is as per specification (i.e.: SSPC SP-11, SP-10, SP WJ-2…).

Verify surface anchor profile using ASTM D4417-Methods B or C against SFLC Std Spec 6310. Conduct profile readings at a minimum of 5 locations for the first 1000-sqft area, and 2 locations for each succeeding 1000-sqft area.

Measure soluble salt conductivity in accordance with SSPC-Guide 15. Conduct 5 measurements per each 1000-sqft area (max. threshold: 70 microsiemens/cm for non-submerged surfaces, 30 microsiemens/cm for submerged surfaces).

CHECKPOINT 6 - PRIMER COAT APPLICATION

Verify environmental conditions (see CHECKPOINT 3).

Verify proper mixing and stand-in (induction) times.

Ensure no paint is applied when the temperature is expected to drop to freezing before the paint has dried.

Ensure surfaces are completely dry, unless otherwise allowed by the coating manufacturer(s).

Verify wet film thickness (WFT) at random, to prevent under or over application. Verify final DFT.

Brush out all runs, sags, drips, and puddles.

Perform visual inspection for holidays and other defects.

CHECKPOINT 7 – STRIPE COAT APPLICATION

Verify environmental conditions (see CHECKPOINT 3).

Ensure overcoating window is as per manufacturer’s instructions.

After primer coat (mist coat after inorganic zinc), brush-apply un-thinned coat of same primer paint over edges, weld seams, cut-outs, and areas of complex geometries @ 3-4 mils wet film thickness (WFT).

CHECKPOINT 8 – TOP COAT APPLICATION

Verify environmental conditions (see CHECKPOINT 3).

Ensure overcoating window is as per manufacturer’s instructions.

Verify proper mixing and stand-in (induction) times, as applicable.

Verify wet film thickness at random, to prevent under or over application.

Brush out all runs, sags, drips, and puddles.

CHECKPOINT 9 – FINAL INSPECTION

Verify final system dry film thickness. Conduct 5 sets of 3 readings for each of the first 3 100-sqft areas, followed by 5 sets of 3 readings for each succeeding 1000-sqft area.

Ensure that system cure is in accordance with manufacturer's recommendation for intended service.

Ensure potable water tank exhaust ventilation is maintained continuously from and during coating application through final sy stem cure, to exhaust all solvent to the atmosphere and to prevent solvent entrapment.

For immersion coatings (including tank U/W body), record date and time of the following events:

Final coat application: _____/_____; Return to service or removal from environment controls: _____/_____

CHECKPOINT 10 – RECORD KEEPING

Complete, sign, and submit all provided QA Inspection Forms.

NAME OF QP-1/AMPP INSPECTOR SIGNATURE CERT. # DATE / TIME

NAME OF CG REPRESENTATIVE SIGNATURE UNIT DATE/TIME

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QA-2 - QUALITY ASSURANCE INSPECTION FORM

(ENVIRONMENTAL READINGS)

VESSEL NAME HULL #

WORK ITEM

Use one sheet for each activity. Record conditions every four hours from before surface preparation to application of final coating system coat.

DATE

TIME

ACTIVITY (SURFACE

PREPARATION, PRIMER COAT,

BARRIER COAT, TOP COAT,

ETC…)

LOCATION (FRAME &

DECK, RELATION TO

EQUIPMENT, ETC.)

TEMPERATURE % REL.

HUMID-

ITY

DEW

PT.

SURFACE AMBIENT ΔT

| DP -

SURFACE |

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QA-3a - QUALITY ASSURANCE INSPECTION FORM

(SURFACE PROFILE LOG FOR PROFILE MEASUREMENTS IAW ASTM D4417-METHOD-C)

VESSEL NAME HULL # WORK ITEM

LOCATION OF WORK (FRAME REFERENCES) AREA (SQFT)

SURFACE PREPARATION METHOD PROFILE ACHIEVED (MILS)

MIN MAX MEAN

SSPC-SP-10/AMPP No. 2

SSPC-SP WJ-2/AMPP WJ-2

SSPC-SP-3

SSPC-SP-11

SSPC-SP-11 (inaccessible area)

Brush-blasting (non-metallic substrate)

ABRASIVE MANUFACTURER: ABRASIVE SIEVE SIZE:

PLACE SURFACE PROFILE REPLICA TAPES IN THE SPACES PROVIDED BELOW, TO SERVE AS

PERMANENT QA RECORD. MAINTAIN A SEPARATE LOG FOR EACH LOCATION. WHEN AN AREA IS

DIVIDED INTO SEPARATE SECTIONS, MAINTAIN A SEPARATE LOG FOR EACH SECTION.

Place Surface Profile Replica Tape Here

Place Surface Profile Replica Tape Here

Place Surface Profile Replica Tape Here

Reading (mils): Reading (mils): Reading (mils):

Place Surface Profile

Replica Tape Here

Place Surface Profile

Replica Tape Here

Place Surface Profile

Replica Tape Here

Reading (mils): Reading (mils): Reading (mils):

Place Surface Profile Replica Tape Here

Place Surface Profile Replica Tape Here

Place Surface Profile Replica Tape Here

Reading (mils): Reading (mils): Reading (mils):

Place Surface Profile Replica Tape Here

Place Surface Profile Replica Tape Here

Place Surface Profile Replica Tape Here

Reading (mils): Reading (mils): Reading (mils):

Place Surface Profile Replica Tape Here

Place Surface Profile Replica Tape Here

Place Surface Profile Replica Tape Here

Reading (mils): Reading (mils): Reading (mils):

MEAN MIL READING (IAW ASTM D4417-METHOD C) FOR ABOVE 15 READINGS:

NAME OF QP-1/AMPP INSPECTOR SIGNATURE CERT. # DATE /

TIME

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QA-3b - QUALITY ASSURANCE INSPECTION FORM

(SURFACE PROFILE LOG FOR PROFILE MEASUREMENTS IAW ASTM D4417-METHOD-B)

VESSEL NAME HULL # WORK ITEM

SURFACE PREPARATION METHOD PROFILE ACHIEVED (MILS)

MIN MAX MEAN

SSPC-SP-10/AMPP No. 2

SSPC-SP WJ-2/AMPP WJ-2

SSPC-SP-3

SSPC-SP-11

SSPC-SP-11 (inaccessible area)

Brush-blasting (non-metallic substrate)

ABRASIVE MANUFACTURER: ABRASIVE SIEVE SIZE:

RECORD MEASUREMENTS TAKEN IN THE SPACES PROVIDED BELOW, TO SERVE AS PERMANENT QA

RECORD. MAINTAIN SEPARATE LOG FOR EACH LOCATION. WHEN AN AREA IS DIVIDED INTO

SEPARATE SECTIONS, MAINTAIN A SEPARATE LOG FOR EACH SECTION.

Reading (mils):

Reading (mils):

Reading (mils):

Reading (mils):

Reading (mils):

Reading (mils):

Reading (mils):

Reading (mils):

Reading (mils):

Reading (mils):

Mean Mils Reading (IAW ASTM D4417-Method B for above 10 readings (by column):

Mean Reading (mils)

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QA-4 - QUALITY ASSURANCE INSPECTION FORM

(SURFACE SOLUBLE SALT CONDUCTIVITY LOG)

VESSEL NAME HULL # WORK ITEM

SOLUBLE SALT CONDUCTIVITY MEASUREMENTS IAW SSPC-GUIDE 15.

DATE TEST LOCATIONS CONDUCTIVITY (MICROSIEMENS/CM)

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QA-5 - QUALITY ASSURANCE DATA FORM

(COATING THICKNESS)

(Use one sheet for each sequence)

VESSEL NAME HULL #

WORK ITEM

COATING MFG PRODUCT NAME

BATC

H #

INDUCTI

ON TIME

COATING SYSTEM

SEQUENCE

(PRIMER/TOUCHUP/3RD

COAT, ETC.)

DRY FILM THICKNESS (DFT) MEASUREMENTS IAW SSPC-PA 2.

SPOT 1 2 3 4 5

AVERAGE

VALUE

*BASE METAL READING

(BMR)

*Required, If Magnetic Pull-Off (Type I/Banana) Gauge Is Used.

LOCATION (FRAME REFERENCE):

SPOT 1 2 3 4 5 OVERALL AVG. DFT ADJUSTMENTS

1 AVG. BMR DEVIATION

3 BEFORE ADJUSTMENTS AFTER ADJUSTMENTS

AVG.

LOCATION (FRAME REFERENCE):

SPOT 1 2 3 4 5 OVERALL AVG. DFT ADJUSTMENTS

1 AVG. BMR DEVIATION

3 BEFORE ADJUSTMENTS AFTER ADJUSTMENTS

AVG.

LOCATION (FRAME REFERENCE):

SPOT 1 2 3 4 5 OVERALL AVG. DFT ADJUSTMENTS

1 AVG. BMR DEVIATION

3 BEFORE ADJUSTMENTS AFTER ADJUSTMENTS

AVG.

APPLICATION METHOD (AIRLESS,

CONVENTIONAL SPRAY, ROLLED)

AVERAGE DFT

12 (Draft-00)

4.2 Tank and Void Assessment form.

13 (Draft-00)

14 (Draft-00)

12314_ESD_0423_FLT

REC_12314_FLT160’ WLIC ‘B’ Class (ALL) (0611)

WORK ITEM 1: Tanks, Potable Water, Clean and Inspect

1. SCOPE

1.1 Intent. This work item describes the requirements for the Contractor to clean and inspect the following tank(s):

TABLE 1 - TANKS

TYPE OF TANK LOCATION CAPACIT

Y - 95%

(GALLON

S)

LOW SUCTION

(GALLONS)

Potable Water 2-34-1-WW 3,306 100

Potable Water 2-34-2-WW 3,306 100

1.2 Government-furnished property.

None.

2. REFERENCES

COAST GUARD DRAWINGS

Coast Guard Drawing 160B WLIC 103-003, Rev-, Booklet of General Plans

COAST GUARD PUBLICATIONS

Surface Forces Logistics Center Standard Specification 0000 (SFLC Std Spec 0000), 2022, General Requirements

OTHER REFERENCES

American National Standards Institute/NSF International (ANSI/NSF) 61, 2015, Drinking Water System Components - Health Effects

15 (Draft-00)

American National Standards Institute/American Water Works Association (ANSI/AWWA) C652, 2011, Disinfection of Water-Storage Facilities

3.1 General.

3.1.1 CIR.

None.

3.1.2 Tech Rep.

Not applicable.

3.1.3 Protective measures. The Contractor must furnish and install all protective measures in accordance with SFLC Std Spec 0000, paragraph 3.3.3 (Vessel component, space, and equipment protection).

3.1.4 Interferences. The Contractor must handle all interferences in accordance with SFLC Std Spec 0000, (Interferences). Known interferences include, but are not limited to the following:

• Fluid contents

• Piping

• RO system components

• Deck grating.

NOTE

Coast Guard personnel will operate all shipboard machinery and equipment.

3.2 Operational test, initial. Prior to commencement of work, the Contractor must witness Coast Guard personnel perform an initial operational test of the equipment listed below to demonstrate existing operational condition. Submit a CFR.

• TLI

3.3 Plug log. The Contractor must keep a written record of all plugs put in any tanks vents. A separate list must be kept for each tank being entered.

3.3.1 Ensure that all plugs are removed from each tank upon completion of work in the tank.

3.3.2 Ensure the plug log is available to the Coast Guard inspector when the inspector is performing his close-out inspection on each tank.

16 (Draft-00)

3.4 Tank content removal. The Contractor must remove and dispose of all fluids and/or residues in accordance with all applicable Federal, state, and local regulations. The Contractor must notify the Dockmaster prior to filling or draining the potable water tank(s), when this item is being executed in a drydock availability. The Contractor must refer to Coast Guard drawings 160B WLIC 103-003 for guidance.

3.5 Tank cleaning. The Contractor must remove tank cover(s); clean tank interior surfaces free of all foreign materials, such as sediment, sludge and bacterial growth. Remove all persistent residues, taking care not to damage any tank coating system. Remove cleaning media and residues continuously from the tank during the washing process. Remove any residual wash media and wipe up residual moisture with clean lint-free cloths. Collect, contain, and dispose of all wash media, residues, and cleaning materials in accordance with all Federal, state, and local regulations.

3.6 Inspection. The Contractor must visually inspect all tank interior surfaces, including, but not limited to bulkheads, floor and overhead plating, structural members, manhole cover surfaces, fasteners and gasket seating surfaces. Complete the “Tank and Void Assessment Form” (found in the Work Item titled “General Requirements”) and submit via CFR. Electronic PDF version of this form will be furnished by the COR upon request. Include the following, as applicable:

• Tank structural condition.

• Inaccessible areas, if any.

• Condition of tank coating, including measurements taken, percentage, location, and type of coating failure.

• Tank level indicator (TLI) and/or float switch condition (if applicable).

• Sounding tube and striker plate condition.

• Suction and discharge piping condition.

• Fastener material and condition.

3.7 Tank closing. The Contractor must notify the COR at least 24 hours prior to closing the tank(s) and ensure tank closure is accomplished in the presence of the Coast Guard Inspector . After satisfactory inspection by the Coast Guard Inspector, and completion of all authorized repairs, close tank manhole cover(s) with new gasket material conforming to ANSI/NSF 61. Renew all stud cotton grommets (as applicable) upon reinstallation of manhole cover(s).

3.7.1 The Contractor must renew 100% of nuts and washers.

3.8 Tank disinfecting. After all other work involving the potable water system and tank closing have been completed, the Contractor must disinfect and treat the affected potable water tank(s) and associated disturbed piping and components, as necessary, to meet or exceed the requirements of AWWA C65 2.

After tank disinfecting, remove and dispose of all treated water in accordance with all Federal, state and local regulations. Ensure that no one enters the tanks once disinfection is completed. Submit CFR providing confirmation that disinfection of tank(s) and associated potable water system disturbed piping and components has been completed and certifying that all sampling and testing is negative for coliform organisms.

17 (Draft-00)

3.9 Operational test, post repairs. After completion of work and in the presence of the Coast Guard Inspector, the Contractor must thoroughly test and demonstrate the equipment listed below to be in satisfactory operating condition. Submit a CFR.

• TLI

4. NOTES

This section is not applicable to this work item.

18 (Draft-00)

12316_0723_FLT

REC_12316_FLT_160’ WLIC ‘B’ Class (ALL) (03813)

WORK ITEM 2: Tanks, Ballast, Clean and Inspect

1. SCOPE

1.1 Intent. This work item describes the requirements for the Contractor to clean and inspect the following

TABLE 1 - TANKS

TYPE OF STRUCTURE LOCATION CAPACITY - 95%

(GALLONS)

LOW SUCTION

(GALLONS)

Ballast Tank 2-17-1-W, Fr 17-27 7,102 70

Ballast Tank 2-17-2-W, Fr 17-27 7,102 70

Ballast Tank 2-139-2-W, Fr 139-145 2,506 50

1.2 Government-furnished property.

None.

2. REFERENCES

Surface Forces Logistics Center Standard Specification 0740 (SFLC Std Spec 0740), 2022, Welding and Allied Processes

OTHER REFERENCES

ASTM International (ASTM) D1330, 2015, Standard Specification for Rubber Sheet Gaskets

19 (Draft-00)

3.1.1 CIR.

None.

3.1.2 Tech Rep.

Not applicable.

3.1.3 Protective measures. The Contractor must furnish and install all protective measures in accordance with SFLC Std Spec 0000, paragraph 3.3.3 (Vessel component, space, and equipment protection).

3.1.4 Interferences. The Contractor must handle all interferences in accordance with SFLC Std Spec 0000, paragraph 3.3.5 (Interferences).

3.2 Operational test, initial. Prior to commencement of work, the Contractor must witness Coast Guard personnel perform an initial operational test of the equipment listed below to demonstrate existing operational condition. Submit a CFR.

• TLI’s for tanks listed in paragraph 1.1

3.3 Plug log. The Contractor must keep a written record of all plugs put in any tanks vents. A separate list must be kept for each tank being entered.

3.3.1 Ensure that all plugs are removed from each tank upon completion of work in the tank.

3.3.2 The plug log must be available to the Coast Guard inspector when the inspector is performing his close-out inspection on each tank.

3.3 Content removal. The Contractor must remove access cover(s); remove and dispose of all fluids and/or residues in accordance with all applicable Federal, state, and local regulations. Plug all inlet and outlet piping in the tank to prevent contaminants from entering the tank. Use plugs with an attached lanyard, ring or other system that will ensure plugs are not lost in the pipe openings. Maintain a plug accountability log outside the tank(s) to prevent any of the installed temporary plugs from being lost inside the tank or forgotten inside at tank closure.

3.4 Cleaning. The Contractor must clean the designated structure’s (see paragraph 1.1 (Intent)) interior surfaces free of all foreign materials, such as sediment, sludge and fungal growth. Remove all persistent residues, taking care not to damage the tank coating system. Remove cleaning media and residues continuously from the compartment during the washing process. Remove any residual wash media and wipe up residual moisture with clean lint-free cloths. Collect, contain, and dispose of all wash media, residues, and cleaning materials in accordance with all Federal, state, and local regulations. The Contractor must refer to Coast Guard drawings 160B WLIC 103-003 for guidance.

20 (Draft-00)

3.5 Inspection. The Contractor must visually inspect all interior surfaces, including, but not limited to bulkheads, floor and overhead plating, structural members, manhole cover surfaces, fasteners and gasket seating surfaces. Complete the “Tank and Void Assessment Form” (found in the Work Item titled “General Requirements”) and submit via CFR. Electronic PDF version of this form will be furnished by the COR upon request. Include the following, as applicable:

• Structural condition.

• Inaccessible areas, if any.

• Condition of coating, including measurements taken, percentage, location, and type of coating failure.

• Tank level indicator (TLI) and/or float switch condition.

• Sounding tube and striker plate condition.

• Suction and discharge piping condition.

• Fastener material (stainless steel) and condition.

• Anodes (as applicable).

3.6 Closing. The Contractor must ensure that the compartment(s) remain open for at least 24 hours after completion of any KO-authorized tank repairs and preservation. Notify the COR at least 24 hours prior to closing the compartment(s) and ensure tank closure is accomplished in the presence of the Coast Guard Inspector. After satisfactory inspection by the Coast Guard Inspector, and completion of all authorized repairs, close the manhole cover(s) with new gasket material conforming to ASTM D1330 and new cotton grommets on each stud (as applicable).

3.6.1 The Contractor must renew 100% of nylon insert/nylock nuts and washers.

NOTE

Coast Guard personnel will operate all shipboard machinery and equipment.

3.7 Operational test, post repairs. After completion of work and in the presence of the Coast Guard Inspector, the Contractor must thoroughly test and demonstrate the equipment listed below to be in satisfactory operating condition. Submit a CFR.

• TLIs

3.8 Ultrasonic thickness (UT) measurement. The Contractor must take a total of 50 UT measurements of tank plating, in locations designated by the Coast Guard Inspector, in accordance with SFLC Std Spec 0740, Appendix C. Use Coast Guard Drawing Coast Guard Drawing 160B WLIC 103-003 as guidance.

Submit a CFR.

3.8.1 In addition to the UT measurements, take a total of _____ pit-depth measurements, using a suitable pit depth gauge

21 (Draft-00)

12316_ESD_0723_FLT

REC_12316_FLT160’ WLIC ‘B’ Class (ALL) (03813)

WORK ITEM 3: Voids, Accessible, Clean and Inspect

1. SCOPE

1.1 Intent. This work item describes the requirements for the Contractor to clean and inspect the following void(s):

TABLE 1 - VOIDS

TYPE OF STRUCTURE LOCATION CAPACITY - 95%

LOW SUCTION

(GALLONS)

Void 2-49-1-V, Fr 49-53 942 50

Void 2-49-2-V, Fr 49-52 942 50

1.2 Government-furnished property.

None.

2. REFERENCES

General Requirements

ASTM International (ASTM) D1330, 2015, Standard Specification for Rubber Sheet Gaskets

22 (Draft-00)

3.1.1 CIR.

None.

3.1.2 Tech Rep.

Not applicable.

3.1.3 Protective measures. The Contractor must furnish and install all protective measures in accordance with SFLC Std Spec 0000, paragraph 3.3.3 (Vessel component, space, and equipment protection).

3.1.4 Interferences. The Contractor must handle all interferences in accordance with SFLC Std Spec 0000, paragraph 3.3.5 (Interferences).

NOTE

Coast Guard personnel will operate all shipboard machinery and equipment.

3.2 Operational test, initial. Prior to commencement of work, the Contractor must witness Coast Guard personnel perform an initial operational test of the TLI’s for tanks listed in paragraph 1.1 (Intent), to demonstrate existing operational condition. Submit a CFR.

3.3 Cleaning and inspection requirements. The Contractor must refer to Coast Guard drawings 160B WLIC 103-003 for guidance. to accomplish the following tasks:

3.3.1 Content removal. The Contractor must remove and dispose of all fluids and/or residues in accordance with all applicable Federal, state, and local regulations.

3.3.2 Cleaning. The Contractor must remove access cover(s). Clean the designated structure’s interior surfaces free of all foreign materials, such as sediment, sludge and fungal growth. Remove all persistent residues, taking care not to damage the tank coating system. Remove cleaning media and residues continuously from the compartment during the washing process. Remove any residual wash media and wipe up residual moisture with clean lint-free cloths. Collect, contain, and dispose of all wash media, residues, and cleaning materials in accordance with all Federal, state, and local regulations.

3.3.3 Inspection. The Contractor must visually inspect all interior surfaces, including, but not limited to bulkheads, floor and overhead plating, structural members, manhole cover surfaces, fasteners and gasket seating surfaces. Complete the “Tank and Void Assessment Form” (found in the Work Item titled “General Requirements”) and submit via CFR. Electronic PDF version of this form will be furnished by the COR upon request. Include the following, as applicable:

• Structural condition.

• Inaccessible areas, if any.

• Condition of coating, including measurements taken, percentage, location, and type of coating failure.

• Tank level indicator (TLI) and/or float switch condition.

• Sounding tube and striker plate condition.

23 (Draft-00)

• Suction and discharge piping condition.

• Fastener material and condition.

3.4 Closing. The Contractor must ensure that the compartment(s) remain open for approximately 24 hours after completion of the tasks specified above. Notify the COR at least 24 hours prior to closing the compartment(s) and ensure tank closure is accomplished in the presence of the Coast Guard Inspector.

After satisfactory inspection by the Coast Guard Inspector, and completion of all authorized repairs, close the manhole cover(s) with new gasket material conforming to ASTM D1330 and cotton grommets on the studs (as applicable). The Contractor must renew up to 10% of missing or damaged nuts and washers.

NOTE

Coast Guard personnel will operate all shipboard machinery and equipment.

3.5 Operational test, post repairs. After completion of work and in the presence of the Coast Guard inspector, the Contractor must thoroughly test and demonstrate the TLI’s for tanks listed in paragraph 1.1 (Intent), to be in satisfactory operating condition. Submit a CFR.

24 (Draft-00)

12317_ESD_0723_FLT

REC_12310_FLT_160’ WLIC ‘B’ Class (ALL) (0121)

WORK ITEM 4: Tanks, Dirty Oil and Waste, Clean and Inspect

1. SCOPE

1.1 Intent. This work item describes the requirements for the Contractor to clean and inspect the following

TABLE 1 – TANKS

TYPE OF TANK LOCATION CAPACITY - 95%

LOW SUCTION

Oily Waste 2-113-1-F 115 25

APM: Determine if indicated tanks have TLI’s, and follow A-Team Note below for possible paragraph removal. *The 110 WPB’s do not have TLI’s.

A-Team Note: If 100% preservation of these tanks is included elsewhere in the package as a definite item, do not include this work item. If this work item is in the package as a definite item, include partial preservation of these tanks as an optional work item in the package.

1.2 Government-furnished property.

None.

2. REFERENCES

COAST GUARD DRAWINGS

None

25 (Draft-00)

Society of Automotive Engineers (SAE) Aerospace Material Specification (AMS) C6183, 2019, Cork and Rubber Composition Sheet; For Aromatic Fuel and Oil Resistant Gaskets

3. REQUIREMENTS

3.1 General.

3.1.1 CIR.

None.

3.1.2 Tech Rep.

Not applicable.

3.1.3 Protective measures. The Contractor must furnish and install all protective measures in accordance with SFLC Std Spec 0000, paragraph 3.3.3 (Vessel component, space, and equipment protection) .

3.1.4 Interferences. The Contractor must handle all interferences in accordance with SFLC Std Spec 0000, paragraph 3.3.5 (Interferences).

3.2 The Contractor must remove up to a total of 100 gallons of waste oil and oily water, to facilitate gas-freeing. Dispose of removed fluids in accordance with all applicable Federal, state, and local regulations.

NOTE

Coast Guard personnel will operate all shipboard machinery and equipment.

3.3 Operational test, initial. Prior to commencement of work, the Contractor must witness Coast Guard Personnel perform an initial operational test of the equipment listed below to demonstrate existing operational condition. Submit a CFR.

• TLI’s for tank(s) listed in paragraph 1.1 (Intent)

3.4 Plug log. The Contractor must keep a written record of all plugs put in any tanks vents. A separate list must be kept for each tank being entered.

3.4.1 Ensure that all plugs are removed from each tank upon completion of work in the tank.

3.4.2 Ensure the plug log is available to the Coast Guard inspector when the inspector is performing his close-out inspection on each tank.

NOTE

Vessel may come in with less tank fluid contents than specified above.

3.5 Cleaning requirements. The Contractor must remove tank cover(s) and clean tank interior surfaces free of all foreign materials, such as sediment or sludge, taking care not to damage the coating system (if

26 (Draft-00) applicable). Remove cleaning media and residues continuously during the washing process. Remove any residual wash media; and wipe up residual moisture with clean lint-free cloths.

3.6 Tank content and waste disposal. The Contractor must dispose of tank contents and all cleaning fluids in compliance with all applicable Federal, state, and local laws, ordinances and regulations. Document a complete chain of custody record of the removed tank contents and generated wastes, from the vessel to the point of final destination or delivery. Submit document to the COR upon completion of work.

3.7 Inspection. The Contractor must visually inspect all tank interior surfaces, including, but not limited to bulkheads, floor and overhead plating, structural members, manhole cover surfaces, fasteners and gasket seating surfaces. Complete the “Tank and Void Assessment Form” (found in the Work Item titled “General Requirements”) and submit via CFR. Electronic PDF version of this form will be furnished by the COR upon request.