TGI_38K4212344A01_c1v1.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.: #1 VCHT RM 4-110-0-E AY A 0 1

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

DDG-105 USS DEWEY K42

CU PHASE TITLE:

F/O - ACCOMPLISH REPAIR AND PRESERVATION OF NO. ONE VCHT ROOM

PREPARING ACTIVITY:

PREPARED BY: CODE PHONE DATE

RYOUSUKE NANBA 231A 315-243-6141 07-AUG-2025

APPROVED BY: CODE PHONE DATE

YUUJI NAKAMURA 231A 315-243-6041 07-AUG-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:

Revision of Reference 2.6 needs to be corrected.

CHANGE INSTRUCTIONS:

CH-1: Correct revision of Reference 2.6. 8/28/2025

SPECIAL REQUIREMENTS:

SURFMEPP

CLEANLINESS FOR PIPING SYSTEM/EQUIPMENT LEVEL III

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.: #1 VCHT RM 4-110-0-E AY A 0

FOUO

SHIP: DDG-105 CHG/VER: 1/1

LIST OF EFFECTIVE PAGES

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

1-7 J1-2 M1-2 Sketch (1-2)

1 SCOPE/PURPOSE:

1.1 Title: Repair and Preservation of No. One VCHT Room 4-110-0-E: accomplish

1.2 Location of Work:

1.2.1 Vacuum Collection Holding Tank (VCHT) Room No. One (4-110-0-E)

1.2.1.1 Sewage Collection Tank No. One

1.2.2 Passage (4-110-1-L)

1.2.3 Fuel Tank Group-2 (5-78-2-F)

1.2.4 IC and Gyro Room No. One (4-94-0-C)

1.2.5 Escape Trunk (4-122-2-T)

1.2.6 Underwater Hull Weather, Frames between 121 and 123, Port

1.3 Identification:

1.3.1 Quantity (One EA), Fuel Tank Group-2

Tank No.: 5-78-2-F Capacity: 16,187 Gallons

1.3.2 Quantity (One Lot/ 5 Tanks), Fuel Tank Group-2

Total Capacity: 70,647 Gallons Required amount of water to dewater: 49,321 Gallons

1.3.2.1 Fuel Receiving Tank Group-2

Tank No: 4-78-1-F Capacity: 11,805 Gallons

1.3.2.2 Fuel Tank Group-2

Tank No: 5-78-2-F Capacity: 16,187 Gallons

1.3.2.3 Fuel Tank Group-2

Tank No: 5-126-2-F Capacity: 19,237 Gallons

1.3.2.4 Fuel Tank Group-2

Tank No: 5-174-4-F Capacity: 21,223 Gallons

1.3.2.5 Fuel Expansion Seawater Overflow Tank Group-2

Tank No: 5-212-4-F

FOUO

SHIP: DDG-105 CHG/VER: 1/1

Capacity: 2,195 Gallons

1.3.3 Quantity (One EA), Sewage Collection Tank No. One

Capacity: 490 Gallons

1.3.4 Quantity (3 EA), Zinc Anode in Sewage Collection Tank No. One Type: ZHC-23

Size: 6 Inches x 6 Inches x 1-1/4 Inches Thickness, Material cut from 12 Inches x 6 Inches x 1-1/4 Inches Thickness ZHC-23 Zinc Anode

1.3.4.1 Quantity (3 EA), Securing Stud

Material: Nickel-Copper Alloy, QQ-N-281 Size: 1/2-13UNC x 2 Inches Thread Length

1.3.5 Quantity (One EA), Manhole Cover Plate(s) for Sewage Collection Tank No. One Size: 23-1/2 Inches Diameter Material: Steel

1.3.6 Quantity (One EA), Bolting Ring for Manhole Cover Plate for Sewage Collection Tank No. One Material: Steel

1.3.7 Quantity (110 SF), Entire Interior Surface of Sewage Collection Tank No. One Remarks: The area including tank side of manhole cover plate and bolting ring

1.3.8 Quantity (One EA), Unknown Doubler Plate on Watertight Transverse Bulkhead Plating Frame 122 in 4-110-0- E, between Margin Plate (P) and Shell Plating (P), Port

Material: Steel, 10.2 LBs Plate Remarks: See Sheet 2 of Sketch Enclosure-01 for location detail

1.3.9 Quantity (One Lot), Watertight Transverse Bulkhead Plating Frame 122 in 4-110-0-E and 4-122-2-T, between Margin Plate (P) and Shell Plating (P), Port, where unknown doubler plate listed in 1.3.8 has been removed

Material: HTS, MIL-S-22698 GR DH-36, 10.2 LBs Plate Remarks: See Sheet 7-12, 7-12-5A of 2.11 for detail and Sketch Enclosure-01 for location detail

1.3.10 Quantity (One EA), Zinc Anode on Margin Plate (P) in 4-110-0-E, Frame 112, Port Type: ZHC-23 Size: 6 Inches x 12 Inches x 1-1/4 Inches Thickness Remarks: See Plan 8AII-4B and Detail 4A-4F of 2.13 for detail

1.4 Security Classification: None.

1.5 Initial Condition:

1.5.1 Dry Dock Work

1.5.2 Critical Coated Area: CCNY-DDG105-020-26 for the area listed in 1.3.7

1.6 Contractor work start date: See attached POP list.

1.7 Contractor work completion date: See attached POP list.

2 REFERENCES:

FOUO

SHIP: DDG-105 CHG/VER: 1/1

REF.

NO.

DOCUMENT

/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV CHG

NO.

COPY

REQ’D

(Y/N)

SOURCE

DOC

(Y/N)

PARA SEC PG CHP

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

3 NSI T-9630-

AB-MMD-

Corrosion Control Assessment and Maintenance Manual (CCAMM)

3 N

4 TM NAVSEA

4790/14

Tank and Void Structural and Coating Condition Survey (MRC G1N5)

- N

5 TM S9086-

CJ-STM-

010/CH-075

Fasteners 7 N

6 DWG 58568-

7300007

SEWAGE COLLECTION TANK

ASSEMBLY

L Y AL

L

7 TM

SYSTEMS &

SPECIFICAT

IONS

SSPC Painting Manual Volume 2 - N

8 DWG 58568-

7300005

SEWAGE COLLECTION TANK

OUTLINE

N Y AL

L

9 DWG 58568-

7300006

TANK WELDMENT - 490 GAL,

CAPACITY

T Y AL

L

10 TM S9593-

CE-MMA-

Sewage Vacuum Collection Holding And Transfer System

10 N

11 DWG 100-

7060380

UNIT STRL ARR DWG ASSY UNIT

C Y SE

E N

OT

E

12 DWG 100-

7060379

UNIT STRL ARR DWG ASSY UNIT

C Y SE

E N

OT

E

13 DWG 633-

7058606

INSTALLATION OF CATHODIC

PROTECTION

C Y SE

E N

OT

E

3 APPENDICIES:

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 Accomplish the requirements of 099-902YO of 2.2 for each tank listed in 1.3.1 and 1.3.3.

5.1.1 Accomplish the requirements of 099-909YO of 2.2 for each tank listed in 1.3.2.

5.1.1.1 Accomplish the requirements of 009-009 of 2.1.

5.1.1.2 Ensure General Cleaning must be Level III.

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SHIP: DDG-105 CHG/VER: 1/1

5.1.2 Accomplish the requirements of 009-107 of 2.1.

5.1.3 Accomplish an assessment of each tank listed in 1.3.3 for existing preservation coating, structural integrity, deterioration, pitting, cracks, and areas of damage or distortion, including sounding tubes, tank/void vents, overflows, piping and associated material, structural members, ladders, anodes, desiccant, tank level indicator (TLI), radar TLI, and their electric cables, stud, and tank top cable penetration, and manhole covers in accordance with 2.3 and 2.4.

Document the assessment on 2.4.

(I) ”CCIMS ASSESSMENT”

5.1.3.1 Submit one legible copy, in hard copy or approved transferrable media, of completed assessment form 2.4 to the SUPERVISOR.

5.1.4 Install each manhole cover for each tank listed in 1.3.3 in accordance with Figures 075-4-1 of 2.5.

5.1.4.1 Install new steel hex head cap screws conforming to Item No. 37 and new steel nuts conforming to Item No.

38 in Parts List of 2.6.

5.2 Commercial blast clean each tank listed in 1.3.3. Accomplish each requirement of Surface Preparation Specification SSPC-SP 6 of 2.7.

5.3 Accomplish a visual inspection of each tank listed in 1.3.3 for existing preservation coating, structural integrity, deterioration, pitting, each crack, and area of damage or distortion, including each sounding tube, tank vent, overflow, piping, each structural member, and manhole cover, using 2.6, 2.8, and 2.9 for guidance.

5.3.1 Submit one legible copy, in hard copy or approved transferrable media, of a report listing results of the requirements of 5.3 to the SUPERVISOR.

5.4 Repair each tank listed in 1.3.3, based on the report 5.3.1 and CCIMS assessment report as designated by the SUPERVISOR, using 2.6, 2.8, and 2.9 for guidance. See 5.17.6.

5.4.1 Base metal weld buildup a total 36 square inches of each plate defects in the tank bottom.

5.4.1.1 For bidding purposes the base metal weld buildup must be one quarter inch thick.

5.4.1.2 Surface must be ground to sound metal prior to base metal weld buildup.

5.4.1.3 Fill each local pit and groove with weld material prior to application of principal buildup layer.

5.4.1.4 Grind each surface of completed base weld metal buildup smooth if greater than 1/8 inch above plate surface.

5.4.2 Accomplish the requirements of 009-012 of 2.1, including Table One, Column(s) D, Lines One through 10.

5.4.2.1 Accomplish nondestructive testing in accordance with Line 14.

5.4.3 Accomplish the requirements of 009-025 of 2.1 for an air hose, water hose, or vacuum box test of each new weld. Allowable leakage: None.

5.5 Remove existing and install new each zinc anode listed in 1.3.4, using 2.6 for guidance.

5.5.1 Chip and grind each surface flush in way of each removal.

5.5.2 Accomplish the requirements of 009-012 of 2.1, including Table 2, Column(s) D, Lines One through 7.

FOUO

SHIP: DDG-105 CHG/VER: 1/1

5.6 Remove and clean each tank flushing nozzle in each tank listed in 1.3.3 and located in 1.2.1, using 2.10 for guidance. Clean each flushing nozzle using detergent/water solution. Detergent solution must conform to MIL-D- 16791.

5.6.1 Accomplish an unobstructed flow test for each flushing nozzle for proper operation and unobstructed flow.

5.7 Accomplish the requirements of 009-032 of 2.1, including Table 3, Line(s) 12, for VCHT room side surface of each cover plate listed in 1.3.5.

5.8 Accomplish the requirements of 009-032 of 2.1, for VCHT room side of each bolting ring listed in 1.3.6.

5.9 Accomplish the requirements of 009-032 of 2.1, including Table 4, Line(s) 16, for each area listed in 1.3.7.

5.9.1 Submit new coating data applied to the SUPERVISOR in accordance with 2.3 and 2.4.

5.10 Install each flushing nozzle removed in 5.6.

5.11 Accomplish the requirements of 009-025 of 2.1 for a completion air test of each tank listed in 1.3.3. Test pressure must be 2 PSIG. Allowable drop in pressure: None.

5.12 Pump out, clean and dry the bilge area located in 1.2.1 free of oil, debris, and other foreign matter.

5.13 Remove each existing unknown doubler plate listed in 1.3.8, using 2.11 and 2.12 for guidance.

5.14 Accomplish visual inspection of each existing bulkhead plating listed in 1.3.9 for structural integrity, deterioration, pitting, cracks, and area of damage or distortion, using 2.11 and 2.12 for guidance.

5.14.1 Submit one legible copy, in hard copy or approved transferrable media, of a report listing results of the requirements of 5.14 to the SUPERVISOR.

5.15 Remove existing and install new each zinc anode listed in 1.3.10 in accordance with 2.13.

5.16 Accomplish the requirements of 009-032 of 2.1 for each new and disturbed surface.

5.17 Notes:

5.17.1 Planner: Code 231A R. Nanba, 243-6141

Planner: Code 231A K. Watanabe, 243-4518 Engineer: Code 250 N. Yokota, 070-3769-2732 Engineer: Code 250 Y. Gouriki, 243-4179

5.17.2 Work Integration Manager (WIM): Code 333 T. Yaginuma, 080-6522-9560

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

5.17.4 This TGI meets the intent of DDG CSWT File Nos. 123-115, 123-116, and 123-133.

5.17.5 This TGI is in response to CCIMS report No. CCIMS-G1N6-DDG105-078-24 from TGI No. 3805Y11007I03.

5.17.6 Removal and installation of interferences, and gas free operation, preservation of boundary spaces relating to front loading structure repair are not included in this TGI. They will be covered by a DL in the future based on Contractor submitted condition report.

5.17.7 SRF-JRMC Code 134 will provide laboratory analysis service for disinfectant solution used for CHT tank when requested by the WIM Code 333.

FOUO

SHIP: DDG-105 CHG/VER: 1/1

5.17.8 2.4 is available on P:\C200\C225\Enclosures\C231\Tank and Void Structural and Coating Condition Survey

(MRC G1N5).

5.17.9 WPC will copy the following pages in reference.

REF. 2.11: Pages 3 12 and 7-12.

REF. 2.12: Pages 3, 6B, and 8.

REF. 2.13: Pages 3C, 4A, and 8AII.

5.17.10 JCNs ER01-ZAM1, ER01-ZAM3, ER01-ZAM5, ER01-ZAM7, ES01-NNYO, and ES01-NNYR are related to this TGI.

5.18 Government Furnished Material (GFM):

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

5.19 SRF-JRMC will provide the following service work: (TGI No. 38K4212344S03).

5.19.1 [C740] Crane and crane rigging service.

5.19.2 [X99E] Utility service, electrical.

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

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

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

5.19.6 [C133] QA Inspection for (G) symbol(s), and review of coating application data.

5.19.7 [C135] QA inspection for (G) symbol(s).

5.19.8 [C250] Technical support for front load repair work.

FOUO

J-1

SHIP: DDG-105 CHG/VER: 1/1

APPENDIX "J"

TGI JOB SUMMARY INFORMATION SHEET

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

VERSION:

CASREP

CAT:

#1 VCHT RM 4-110-0-E AY A 0 1

CU PHASE TITLE:

F/O - ACCOMPLISH REPAIR AND PRESERVATION OF NO. ONE VCHT ROOM

PRIMARY COMPONENT:

COMPONENT UNIT LIST (FOR ASSEMBLIES):

ZONE 1 FR0-FR126P UH CMPT 4-110-0-E MS VCHT 4-110-0-E TKZINC VCHT 4-110-0-E ZI

CMPT 4-94-0-C MSFOCT 5-78-2-F TK TRUNK 4-122-2-T MS CMPT 4-110-1-L MS

ATTACHMENT LIST:

1. ENCLOSURE-01 (38K4212344A01-Sketch.pdf) saved on 05-AUG-2025 0000.

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

YAGINUMA ,TAKEHIDE

JO: KO: TOTAL MAN HRS: TOTAL DURATION: PLANNING ACCEPTANCE:

38K4212344 A01

TOTAL MAT’L COST

CU PHASE DESCRIPTION:

The purpose of this TGI is to accomplish repair and preservation of No. One Vacuum Collection Holding Tank Room.

Location of Work:

Vacuum Collection Holding Tank Room No. One (4-110-0-E) Sewage Collection Tank No. One Passage (4-110-1-L) Fuel Tank GP-2 (5-78-2-F) IC and Gyro Room No. One (4-94-0-C) Escape Trunk (4-122-2-T) Underwater Hull Weather, Frames between 121 and 123, Port

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

5.1 LBR , QA 22 KE PC 0

5.2 PNTR , ELEC , QA 22 KE PC 0

5.3 PNTR 22 KE PC 0

5.4 WELD , QA 22 KE PC 0

5.5 SFTR , WELD , PNTR , STML , INSL , QA 22 KE PC 0

5.6 PFTR 22 KE PC 0

5.7 PNTR , QA 22 KE PC 0

5.8 PNTR , QA 22 KE PC 0

5.9 PNTR , ELEC , QA 22 KE PC 0

5.10 PFTR 22 KE PC 0

5.11 SFTR 22 KE PC 0

FOUO

J-2

SHIP: DDG-105 CHG/VER: 1/1

TASK NAME

SHOP TSD/WC TS CREW# MHRS

HIGH RAD

HOURS

RC

GRID#

5.12 SFTR , LBR 22 KE PC 0

5.13 SFTR , WELD , PNTR , RGRS , QA 22 KE PC 0

5.14 SFTR 22 KE PC 0

5.15 SFTR 22 KE PC 0

5.16 PNTR , QA 22 KE PC 0

Dewatering and Cleaning Work CFM: for marine chemist, chemical, gaskets, fasteners, tank watch cost, and misc.

22 MQ CS 0 0 0

Preservation Work CFM: for all paints, thinners, grit, tank watch cost, covering material, and misc such as consumable.

22 MQ CS 0 0 0

Piping Work CFM: for tank watch cost, detergent cost, and misc.

22 MQ CS 0 0 0

Structure Work CFM: for all paints, thinner, fire watch cost, tank watch cost, sampling/analysis cost, and misc such as electrode, gases, covering material, and other consumable.

22 MQ CS 0 0 0

Process Funding Document 10 CT OM 1 1 0

Version-01: correct revision of Ref. 2.6. C231A Y. Nakamura, 8/28/2025. Y/Y/N

V-01 0 0 0

FOUO

M-1

SHIP: DDG-105 CHG/VER: 1/1

APPENDIX “M”

TGI MATERIAL LIST

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

VERSION:

CASREP

CAT:

#1 VCHT RM 4-110-0-E AY A 0 1

CU PHASE TITLE:

F/O - ACCOMPLISH REPAIR AND PRESERVATION OF NO. ONE VCHT ROOM

MATERIAL REFERENCES

REF

NO.

DOCUMENT/DRAWING

NUMBER

DOCUMENT/DRAWING TITLE REV

JOB ORDER: KEY OP:

38K4212344 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 M ANODE,CORROSION PRE,

ORDERED FOR KTR

ORIGINATOR: C231A, R.

NANBA, 243-6141

9B 5342 008136058 NA 4 N 52215002 3/EA

003 M STUD,PLAIN, ORDERED FOR

KTR

ORIGINATOR: C231A, R.

NANBA, 243-6141

9B 5307 013931920 NA 4 N 52215004 6/EA

004 M LOCKWASH, LOCKWASHER,

EXTERNAL TOOTH, 1/2"

NOMINAL, 410 STAINLESS

STEEL. DWG: 7300007 PC-39.

ORDERED FOR KTR

ORIGINATOR: C231A, R.

NANBA, 243-6141

9B 5310 LL9306153 NA 4 N 52217401 6/EA

005 M NUT,SELF, ORDERED FOR

KTR

ORIGINATOR: C231A, R.

NANBA, 243-6141

9B 5310 002453504 NA 4 N 52215005 6/EA

006 M INSULATI, ORDERED FOR KTR

ORIGINATOR: C231A, R.

NANBA, 243-6141

9Q 5640 013713263 NA 4 N 52215006 10/SH

NOTES:

FOUO

M-2

SHIP: DDG-105 CHG/VER: 1/1

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

007 M TAPE,TEX, ORDERED FOR

KTR

ORIGINATOR: C231A, R.

NANBA, 243-6141

9B 8315 002671632 NA 4 N 52215007 1/RO

008 M CAP, STUD, ORDERED FOR

KTR

ORIGINATOR: C231A, R.

NANBA, 243-6141

9B 5340 LL4945008 NA 4 N 52217402 30/EA

009 M ADHESIVE, ORDERED FOR

KTR

ORIGINATOR: C231A, R.

NANBA, 243-6141

9B 8040 002738708 NA 4 Y 52215008 1/GL

100 M ANODE,CO, ORDERED FOR

KTR

ORIG:C-231A, WATANABE 243-

9B 5342 008136058 NA 4 N 52095028 1/EA

101 M WASHER,L, ORDERED FOR

KTR

ORIG:C-231A, WATANABE 243-

9B 5310 015492705 NA 4 N 52095029 2/EA

102 M NUT,SELF, ORDERED FOR

KTR

ORIG:C-231A, WATANABE 243-

9B 5310 005957421 NA 4 N 52095031 2/EA

400 M INSL, 6" IPS, INSULATION,

PIPE,

BRAND: K-FLEX ECO,

SPECIFICATION COMPLIANCE:

EB 4013,

FOR SIZE: 6" IPS,

SIZE: 6-5/8" ID X 3/4" THK X 6FT

LG,

UI: EA/6 FT (ONE

CONTINUOUS LENGTH

REQUIRED),

MATL: NON-HALOGEN, 2

EA/BOX.

*MUST BE ORDERED IN

MULTIPLES OF 2EA*

*MSM AVAILABLE*

9B 5640 LL9607850 NA 4 N 52067423 2/EA

401 M INSL, 8" IPS, INSULATION,

PIPE,

BRAND: K-FLEX ECO,

SPECIFICATION COMPLIANCE:

EB 4013,

FOR SIZE: 8" IPS,

SIZE: 8-5/8" ID X 3/4" THK X 6

FT LG,

UI: EA/6 FT (ONE

CONTINUOUS LENGTH

REQUIRED),

MATL: NON-HALOGEN,

1EA/BOX.

*MSM AVAILABLE*

9B 5640 LL9607851 NA 4 N 52067424 2/EA

402 M ADH FOR PLASTIC TUBE,

ADHESIVE FOR PLASTIC TUBE

9B 8040 008419773 NA 4 Y 52065069 2/PT

403 M ADH FOR CLOTH, ADHESIVE

FOR CLOTH

9B 8040 002738708 NA 4 Y 52065071 1/GL

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:

DDG-105 #1 VCHT RM 4-110-0-E AY A 0

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

38K4212344 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:

DDG-105 #1 VCHT RM 4-110-0-E AY A 0