CU ST OM ER OWN ED SAF ET Y CH ECK L I ST

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					                                                                                      CU ST OM ER-OWN ED SAF ET Y CH ECK L I ST
                                                                                     ST AT I ON ARY & M OB I L E L OX/L I N /L AR/L H Y
                                                                                                                 L I QU I D SYST EM S

CUSTOMER NAME                                                               SHIP-TO PARTY #           PRODUCT            DATE


CUSTOMER ADDRESS                                                            ORDER #                   EQUIPMENT ID       INSPECTOR


TANK INFORMATION
TANK SIZE         ORIENTATION (Circle)     MANUFACTURER                  DATE OF MFG.     N/B #              MAWP          RELIEF VALVE SET POINT
                  Vert  Horiz  Spher


I. INSPECTION OF LIQUID SYSTEM
     The list below is to aid Air Products’ customers in maintaining their equipment and to ensure the safety of Air Products’ personnel
     while delivering product. The checklist is intended to highlight items affecting the safe delivery of product, not as a maintenance
     guide for customer-owned systems. Air Products recommends periodic inspection of liquid nitrogen, argon, oxygen and medical
     care facility systems to ensure safe and reliable operations. Items found deficient should be promptly repaired.

     NEW**PICTURES ARE REQUIRED OF OVERALL SYSTEM, INCLUDING DELIVERY ACCESS.
          PICTURES ARE REQUIRED FOR ANY “NO” ANSWERS.

A.     LOX, LIN, AND LAR SYSTEMS                                                                                           YES       NO    N/A
      STATIONARY AND MOBILE UNITS
       1.   Are all tanks properly marked with the product name and hazard warning?
       2.   If the answer to question #1 is “NO”, have you installed a generic hazard warning decal (LOX
            Code # 4-280-51-0578, LIN Code # 4-280-51-0579, LAR Code # 4-280-51-0582), LHY Code
            # 4-280-51-0580
     3a.    Is there a generic installation data decal installed on the tank?
     3b.    If the answer to 3a is no, have you installed a generic data decal using Code No. 4-280-51-0744,
            and have you filled in the operating parameters?
      3c.   Has the SAP Customer Number (Ship-to party #), Tank Number, and National Board Number (in
            parenthesis behind SAP No.) been entered on the tank data decal?
       4.   Is there cold product in the tank (open manual vent valve to verify)? * Liq Level ________ inches.
       5.   Is the unloading area free from obstructions that would prevent delivery or create a hazard for
            the driver? (If marked no, explain)
       6.   Are the appropriate fill connections, in accordance with CGA Pamphlet V-6, installed to eliminate
            the need for adapters?
       7.   Is the vessel equipped with a fill line check valve, and is it operational?
       8.   Is the fill line equipped with a hose drain valve? (LOX, LIN, LAR only).
       9.   Is the fill connection threaded, welded or silver brazed to the piping? (Soft solder is not acceptable
            on fill circuit. Any solder requiring flux, 35% silver or above, is acceptable. If soft solder is used on
            other piping, except for gaseous lines on non flammable product with tank MAWP less than 150
            psig, notify the local APCI engineer to warn the customer of Code violation.)
     10.    Is the fill connection fitting anchored to prevent separation in the event the joint fails during filling?
            (LOX, LIN, LAR only)
     11.    Do all fill line components appear to be rated for a minimum of 300 psig? (LOX, LIN, LAR only)
     12.    Has the fill line, up to the fill valves, been pressure tested to 300 psig? For higher MAWP tanks, has
            the fill line been pressure tested to 110% of the MAWP? If the customer is unable to verify, system
            must be tested by APCI. If a pressure test is performed, call EST(800-489-6677) as a new billable
            work order will be created. Please sign below once the pressure has been tested.

            Pressure Test Verification:


                          Technician/Customer Signature                       Date                    Phone Number

     13.    Are all valves used for filling the tank operable?
     14.    If there are Rego valves on the tank with left handed threaded bonnet nuts, are they protected with
            APCI designed collars? (Mark N/A if no Rego valves with LH threads on tank.)


Form # 3773                                                              Page 1 of 9                                             Rev. 4/29/10 KAL
                                                                                  CU ST OM ER-OWN ED SAF ET Y CH ECK L I ST
                                                                                 ST AT I ON ARY & M OB I L E L OX/L I N /L AR/L H Y
                                                                                                             L I QU I D SYST EM S

           Customer Name_______________________ Ship-to Party #________________________                               YES     NO      N/A
    15.   Is all system piping either copper or stainless steel? (excluding vaporizers)
    16.   Do all vents discharge in a safe location away from the driver?

    17.   Do all vent lines discharge in a safe location, with no danger of being plugged with snow or ice?
  18a.    Is the vessel equipped with a working pressure gauge and a liquid level indicator? (A working
          telemetry unit is an acceptable liquid level indicator)

  18b.    If the answer to 18a is yes, does the pressure gauge appear to be working?
    19.   Is the vessel equipped with a full trycock, and is it operational?
  20a.    Is the MAWP of the tank greater then 150 psig? If YES, skip to question 21, otherwise, continue
          to 20b. (LOX, LIN, LAR only)
  20b.    If the answer to question 20a is “NO”, has an overfill protective device (i.e., Fill Line Closure
          Device (FLCD) been installed? (LOX, LIN, LAR only)
   20c.   If the answer to question 20b is “Yes”, who manufactured the over-fill protective device? (See note
          on page 4)
  20d.    If the answer to question 20a is “No”, fill out the Low Pressure Tank Data Collection Sheet found in
          Appendix A.
    21.   Is the relief valve set point less than or equal to the MAWP of the tank?
    22.   Do the main tank safety relief valves appear to be a full flow device and not a thermal relief valve?
          (Example - Is the valve a coded safety relief device with a wire seal.)
   23a.   Is the tank fitted with a vacuum relief plate, or rupture disc? (If not sure mark no and add comment.)
   23b.   If the answer to 23a is yes, and you can inspect it, is it free to lift in the event of pressure in the
          vacuum space (no clamps or bolts)? (Issue to be resolved by discussion with equipment owner)
    24.   Does the customer have a liquid use line that enters a building?
    25.   If the answer to question 24 is yes, are all relief devices and automatic vent valves on the liquid
          supply line vented outdoors?*
    26.   If the tank is located indoors, are all the safety relief valves, rupture discs, the manual vent, and
          trycock piped outdoors?
    27.   Is the vessel a standard cryogenic vessel designed for the product for which it will be filled?
    28.   If the vessel was made by Linde, Taylor Wharton, or UCAR, and the date of mfg is between 1964 –
          1985, regardless of tank size, has the original brass tee with plug between the SS liquid fill
          penetration and PB inlet been replaced by a copper adapter and reducing tee? U bolt temporary fix
          is acceptable. Ref MB 02.32.
    29.   Is the installation in an open space that could not be considered a hazard to the delivery driver?

    30.   If this tank is installed at a health care facility complete item 30a OR 30b.
   30a.   Size of Reserve Tank ________gallons
   30b.   No. of Reserve Cylinders_______ Size of reserve Cylinders______ Pressure Rating _______psig

     STATIONARY UNITS ONLY
    31.   If multiple tanks, are the fill connections easily distinguishable for product?
    32.   Is the fill line LESS than 50 ft? (If longer, the site fails until engineer reviews anchoring, and design
          for thermal contraction.)
    33.   If electronics grade, are clam shells installed on valves per 14.20.428?
    34.   Is the system anchored?
    35.   Answer NO if the customer plans on moving the system after fill.
    36.   Is the tank on a concrete pad? If other surface, photos must be taken and notes provided.

Form # 3773                                                            Page 2 of 9                                          Rev. 4/29/10 KAL
                                                                                     CU ST OM ER-OWN ED SAF ET Y CH ECK L I ST
                                                                                    ST AT I ON ARY & M OB I L E L OX/L I N /L AR/L H Y
                                                                                                                L I QU I D SYST EM S

      Customer Name_______________________ Ship-to Party #________________________                                       YES     NO      N/A

B     SPECIFIC REQUIREMENTS FOR LOX SYSTEMS IN ADDITION TO THOSE LISTED IN SECTION A
     STATIONARY AND MOBILE UNITS
      1.   Is the tank installed on a noncombustible surface? (Asphalt and macadam are considered
           combustible. The noncombustible surface should extend three (3) feet beyond areas where
           leakage could occur.)
      2.   Is a noncombustible unloading pad provided for the trailer and in good condition? (asphalt and
           macadam are combustible, the size requirement is 12’ x 8’ nominal per NFPA 50)
      3.   Is the system located a minimum of 50’ away from hazards such as flammable liquids/gas storage?
           NO answer to be evaluated by Field Engineer.
      4.   Are all Liquid Hydrogen storage systems at least seventy-five (75) feet away from the system?
      5.   Is the area free of weeds or other combustible materials? (Minimum of 15’ from the installation.)

      6.   Are sewer inlets and storm drains 8” from connection and 8’ around unloading pad?
      7.   If the storage vessel was fabricated by Air Products, is the inner vessel material fabricated by
           materials other than aluminum? (If not sure of inner vessel material check “no” and add comment.)
      8.   If this tank is installed at a health care facility, can the customer verify that the alarm reserve in- use
           alarm, reserve low pressure, and main and reserve low level alarms operational (excludes transfill
           facilities) are operational?* If the customer is unable to verify, system must be tested by APCI. If a
           function test is performed, call EST as a new billable work order will be created.
            Please sign below once the function test has been completed.



                         Technician/Customer Signature                       Date                   Phone Number


C.   SPECIFIC REQUIREMENTS FOR LHY SYSTEMS IN ADDITION TO THOSE LISTED IN SECTION A
      STATIONARY UNITS ONLY
      1.   Has the LHY system been reviewed by an engineer? (Requirement for all LHY systems)

      2.   Are all liquid hydrogen lines, where liquid air will form, installed over clean gravel or concrete? (Any
           lines where liquid air may form should not be run over asphalt or combustible materials.)
      3.   Are all safety valves, relief devices, and vents piped to a vent stack that terminates in a safe
           location? (25’ above grade is a recommended minimum.)
      4.   Is the vessel equipped with an operational full trycock (neon-filled) gauge and the discharge from the
           full trycock piped to the vent stack?
      5.   If the installation is fenced, is there a personnel gate installed that will provide an alternate means of
           egress in the event of a situation that prohibits the use of the main gate?
      6.   Is the system electrically grounded?
      7.   Is the area within fifty (50) feet of the system free from sources of ignition?
      8.   Are electrical systems within twenty-five (25) feet of the system explosion proof? (Class I, Div. 2,
           Group B; if within three (3) feet of fill connection, Div. I)
      9.   Is the area free of weeds or other combustible materials? (Minimum of 25’ from the installation.)
     10.   Is concrete or clean gravel provided under the liquid hydrogen tank piping and under those portions
           of the liquid tanker off-loading area where liquid air may drop during the transfer of product? (14’ x
           30’ area recommended for trailer.)
     11.   Is the system labeled to indicate “Liquid Hydrogen – Flammable Gas – No Smoking – No Open
           Flame”?
     12.   Is a remote operated fire control valve installed on the liquid withdrawal line for vessels over 2,000
           gallons?


Form # 3773                                                             Page 3 of 9                                            Rev. 4/29/10 KAL
                                                                                             CU ST OM ER-OWN ED SAF ET Y CH ECK L I ST
                                                                                            ST AT I ON ARY & M OB I L E L OX/L I N /L AR/L H Y
                                                                                                                        L I QU I D SYST EM S

       13.     Is the fill line equipped with a fill hose purge line and is the line piped to the vent stack? (This line will
               also serve as the hose drain line.)
       14.     Is the location of the emergency shutoff valve clearly marked and obvious to the driver?
       15.     Is the vent stack top designed per CGA G5.5?
       16.     Are guy wires installed on vent stack for support?
       17.     Are all vent stack discharges oriented to prevent a hazardous condition? SHOULD WE KEEP THIS?
       18.     Are all wall openings (doors and windows) and air intakes (air conditioning and air compressors) at
               least seventy-five (75) feet away from the system?

       19.     Are all Liquid Oxygen storage systems at least seventy-five (75) feet away from the system?
       20.     Are all flammable liquid and flammable gas storage systems (excluding hydrogen) at least 100 feet
               away from the system?

II. DELIVERY RELATED INSPECTION
       STATIONARY AND MOBILE UNITS
        1.     Is there adequate room for an APCI tanker to maneuver?
        2.     Can unloading occur without the tanker being parked over railroad tracks?
        3.     Can unloading occur without the tanker being parked over a sidewalk?
        4.     Can unloading occur without the tanker being on an excessive grade?
        5.     Can unloading occur without the tanker being on unstable ground?
        6.     Is the access way and loading area free of overhead obstructions such as power lines, structural
               items, pipes, or pipe racks?
        7.     Can unloading occur w/o the tanker backing into the unloading area, or unloading from an active
               road?
        8.     Is there adequate lighting to allow deliveries at night? (Additional fees may be required if restricted to
               daylight deliveries-cost to serve issue.) *
        9.     Is the site accessible with only one transfer hose?
       10.     Are there any bridges at the plant site?
      10a.     If yes to question 10, are they adequate capacity (at least 80,000 lb.) to allow delivery access?




NOTES SECTION
  •     Any “NO” or “N/A” items must be fully explained; use the back of the form or a separate paper. As appropriate please attach a
        sketch to help detail your explanation.
  •     Fax the completed form with any explanations to EST via (610) 481-8648 as soon as the inspection is completed.
  •     Any items with an “*” after them means the vessel can be filled pending the resolution of this issue.
  •     20c. If there is an over-fill protective device other than a FLCD manufactured by Blackhall Engineering LTD installed, contact
        engineering on the spot for further instructions. A FLCD manufactured by Blackhall Engineering LTD is the only acceptable
        overfill protective device not required to have additional documentation submitted stating that the installed device will eliminate
        the hazard of over-pressurization.


                     Inspector’s Signature                                      Date                                                Phone Number



             PRINT Customer Contact’s Name, if any              Addt’l information not on checklist, if any, which was passed on to contact person (Add attached page).




Form # 3773                                                                    Page 4 of 9                                                         Rev. 4/29/10 KAL
                                                                                 CU ST OM ER-OWN ED SAF ET Y CH ECK L I ST
                                                                                ST AT I ON ARY & M OB I L E L OX/L I N /L AR/L H Y
                                                                                                            L I QU I D SYST EM S



Customer Name_______________________ Ship-to Party #________________________

                                  Low Pressure Tank Data Collection Sheet

*COMPLETE DATA SHEET ONLY IF THE MAWP OF THE TANK IS LESS THAN 150 PSIG (QUESTION A-20a)

IMPORTANT – The following questions must be answered
Does the customer have more than one low pressure unit which Air Products will be filling?           Yes       No
If so, are these units available for inspection today? If not, another visit will be necessary.      Yes       No

1. GENERAL INFORMATION
 NOMINAL TANK VOLUME                    TANK ORIENTATION               TANK TYPE
                                           Vertical                       Stationary Tank
                                                                          Mobile Tanker
      _________US gallons                  Horizontal
                                                                          ____________________


 TANK OWNERSHIP                                                          TANK MANUFACTURER
    APCI Owned              APCI Tank ID #______________                   MVE (Chart)  APCI           Linde        ____________
    Customer Owned          Customer ID #_______________                   PEI (Chart)  TW             Ryan


 PRODUCT               TANK MAWP                     Manufacturer Model # _________________           TANK FILLED BY:
    LOX                                                                                                  APCI Tanker Pump
                                                     Manufacturer Serial #__________________
    LIN                                                                                                  Ground Pump
    LAR                                              National Board #______________________              ________________
                             ________PSIG
    LHY                                              Date Manufactured


COMMENTS________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

2 .DIVERTER VALVE
 DIVERTER MFG                              MODEL :                        DIVERTER INLET           DIVERTER BODY
      TBV                                                                       1/2”                     1/2”
      Worchester                                                                3/4”                     3/4”
      Blackhall                                                                 1”                       1”
      Rockwood Swendeman                                                        1 ½”                     1 ½”
      ____________________                                                      2”                       2”
                                                                                2 ½”                     2 ½”


 RELIEF VALVE PORT                BURST DISC PORT
        1/2”                            1/2”
        3/4”                            3/4”
        1”                              1”
        1 ½”                            1 ½”
        2”                              2”
        2 ½”                            2 ½”

COMMENTS________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Form # 3773                                                           Page 5 of 9                                     Rev. 4/29/10 KAL
                                                                                CU ST OM ER-OWN ED SAF ET Y CH ECK L I ST
                                                                               ST AT I ON ARY & M OB I L E L OX/L I N /L AR/L H Y
                                                                                                           L I QU I D SYST EM S
___________________________________________________________________________________________________________
3. SAFETY RELIEF VALVE(S)
                                                                                           Yes        No
 Is MORE than one relief valve on-line at any time? If yes, specify the number of valves.
                                                                                          No. of valves:

                                                                                                 Yes      No
 Are valves EXACTLY the same with regard to manufacturer, size, and relief setting? If not,
                                                                                               Other:
 please provide detail of each valve.



 MANUFACTURER                  MODEL:                        OPERATION                   VALVE INLET                 VALVE OUTLET
    Rockwood                                                                                 1/2”                        1/2”
    AGCO                                                        Spring operated              3/4”                        3/4”
    IMI-Cash                                                    Pilot operated               1”                          1”
    ____________                                                                             1 ½”                        1 ½”
                                                                                             2”                          2”
                                                                                             2 ½”                        2 ½”

 Set Pressure                                                                                   psig
 Internal Orifice Size                                                                          square inches       and/or       scfm
 Does piping exist on OUTLET of relief valve OTHER than a single elbow and short
                                                                                                   Yes         No
 pipe nipple used to direct flow downward?
 If discharge piping does exist, do multiple discharge lines tie together into a
                                                                                                   Yes         No        N/A
 header?
 Please provide the following information for discharge piping:
 Nominal Line Size
                                                                                                 inches
 Equivalent Straight Run Length of Piping*
                                                                                                 feet
 No. of Elbows
                                                                                                 elbow(s)
 No. of Tee Runs
                                                                                                 tee run(s)
 No. of Tee Branches
                                                                                                 tee branches(s)

 Are there any block valves located in the discharge piping? If yes, specify the
                                                                                                    Yes         No
 number of valves.
                                                                                       No. of valves:

 Please describe type (i.e. globe, ball, 3-way, etc.) AND size of valves.              Type:


                                                                                       Size:


COMMENTS________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

4. RUPTURE DISKS
 MANUFACTURER                    MODEL:                   DISC TYPE                  INLET CONNECTION               DISC SIZE
     Continental                                            One Piece Disc/              1/2”                           1/2”
     BS&B                                                 Holder Assembly                3/4”                           3/4”
     Fike                                                   Flange Holder                 1”                            1”
     Elfab                                                  Union                        1 ½”                           1 ½”
     Oseco                                                  ____________                 2”                             2”
     __________                                                                          2 ½”                           2 ½”




Form # 3773                                                          Page 6 of 9                                        Rev. 4/29/10 KAL
                                                                                    CU ST OM ER-OWN ED SAF ET Y CH ECK L I ST
                                                                                   ST AT I ON ARY & M OB I L E L OX/L I N /L AR/L H Y
                                                                                                               L I QU I D SYST EM S


 Burst Pressure and Temperature                                                                       psig        ˚F
 Does piping exist on outlet of disc (i.e. Pipe-A-Way, etc.)?                                           Yes        No
 If discharge piping does exist, do multiple discharge lines tie together into a                        Yes        No     N/A
 header?
 Please provide the following information for discharge piping:
 Nominal Line Size
                                                                                                     inches
 Equivalent Straight Run Length of Piping*
                                                                                                     feet
 No. of Elbows
                                                                                                     elbow(s)
 No. of Tee Runs
                                                                                                     tee run(s)
 No. of Tee Branches
                                                                                                     tee branch(es)

 Are there any block valves located in the discharge piping? If yes, specify the
                                                                                                        Yes      No
 number of valves.
                                                                                           No. of valves:

 Please describe type (i.e. globe, ball, 3-way, etc.) AND indicate size of valves.         Type:


                                                                                           Size:


COMMENTS________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________

5. EXTERNAL LINE SIZES AND LENGTHS
 CGA FILL CONNECTION        FILL LINE PIPING                    VENT LINE PIPING
 NOMINAL SIZE               MATERIAL                            MATERIAL
                                                                   SS
       1”                        SS
                                                                   Copper
      1 ½”                       Copper                            ________
      2”                         ________
      2 ½”
      _____


 Does the tank currently have a Fill Line Orifice Plate? If so, please provide orifice                Yes       No
 area (square in) or diameter (inches).                                                    Size:
 Does the tank have Top Fill Circuits?                                                                Yes       No




 Does the tank have Bottom Fill Circuits?                                                             Yes       No
 Does a check valve exist in the fill line? If so, please indicate the manufacturer                   Yes       No
 and size of the check valve.                                                              Manufacturer:
                                                                                           Size:

COMMENTS________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________



Form # 3773                                                          Page 7 of 9                                        Rev. 4/29/10 KAL
                                                                                CU ST OM ER-OWN ED SAF ET Y CH ECK L I ST
                                                                               ST AT I ON ARY & M OB I L E L OX/L I N /L AR/L H Y
                                                                                                           L I QU I D SYST EM S
 Top Fill Line Nominal Pipe Size                                                          3/4”            1 ½”        ________
                                                                                          1”              2”
 Does pipe remain constant from fill connections to tank? If no, please explain.                    Yes          No



 Top Fill Line Equivalent Straight Run Length*:                                                   feet
 Number of in-line valves (Top-Fill):                                                            valve(s)
 Please describe type (i.e. globe, ball, 3-way, etc.) AND indicate size of valves.     Type:


                                                                                       Size:

 No. of 90 ˚ Elbows:                                                                             elbow(s)
 Nominal Size:                                                                                    inch
 No. of 45 ˚ Elbows:                                                                             elbow(s)
 Nominal Size:                                                                                    inch
 No. of Tee Runs:                                                                                 tee run(s)
 Nominal Size:                                                                                    inch
 No. of Tee Branches:                                                                             tee branch(es)
 Nominal Size:                                                                                    inch

 Bottom Fill Valve Manufacturer                                                            Bestobell
                                                                                           Goddard
                                                                                           Herose
                                                                                           Powell
                                                                                           Rego
                                                                                           Goddard Gate
                                                                                           Other:

 Bottom Fill Line Nominal Pipe Size                                                       3/4”            1 ½”        ________
                                                                                          1”              2”
 Does pipe remain constant from fill connections to tank? If no, please explain.                    Yes          No



 Bottom Fill Line Equivalent Straight Run Length*:                                                feet
 Number of in-line valves (Bottom-Fill):                                                         valve(s)
 Please describe type (i.e. globe, ball, 3-way, etc.) AND indicate size of valves.     Type:


                                                                                       Size:

 No. of 90 ˚ Elbows:                                                                             elbow(s)
 Nominal Size:                                                                                    inch
 No. of 45 ˚ Elbows:                                                                                      elbow(s)
 Nominal Size:                                                                                   inch
 No. of Tee Runs:                                                                                tee run(s)
 Nominal Size:                                                                                   inch
 No. of Tee Branches:                                                                            tee branch(es)
 Nominal Size:                                                                                   inch
 Main Vent (Relief) Line Nominal Pipe Size                                                1”          1 ½”
                                                                                          2”           ________
 Does pipe remain constant from Tank to INLET OR RELIEF DEVICE(S)? If no,                           Yes      No
 please explain.
 Main Vent Line Equivalent Straight Run Length*:                                                  feet
 Number of in-line valves between TANK and INLET OF RELIEF DEVICE(S):                            valve(s)

Form # 3773                                                          Page 8 of 9                                       Rev. 4/29/10 KAL
                                                                                CU ST OM ER-OWN ED SAF ET Y CH ECK L I ST
                                                                               ST AT I ON ARY & M OB I L E L OX/L I N /L AR/L H Y
                                                                                                           L I QU I D SYST EM S
 Please describe type (i.e. globe, ball, 3-way, etc.) AND indicate size of valves.      Type:


                                                                                        Size:

 No. of 90 ˚ Elbows:                                                                             elbow(s)
 Nominal Size:                                                                                    inch
 No. of 45 ˚ Elbows:                                                                             elbow(s)
 Nominal Size:                                                                                    inch
 No. of Tee Runs:                                                                                 tee run(s)
 Nominal Size:                                                                                    inch
 No. of Tee Branches:                                                                             tee branch(es)
 Nominal Size:                                                                                    inch

COMMENTS________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
* “Equivalent Straight Run Length” is determine by measuring individual sections of same-size piping and adding the lengths
together to arrive at a single equivalent length. If a circuit contains more than one nominal size of piping, the equivalent straight run
length of each size must be calculated separately and a note should be made indicating the various line lengths.




Form # 3773                                                          Page 9 of 9                                        Rev. 4/29/10 KAL

				
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