HomeMy WebLinkAboutConstruction Completion Report Form.pdfW
Health CONSTRUCTION COMPLETION REPORT FORM
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In accordance with WAC 246-290-120 (5), a Construction Completion Report is required for all approved construction projects.
Operators must submit a Construction Completion Report to us within sixty (60) days of completion and before use of any water
system facility. This includes any source, water quality treatment, storage tanks, booster pump facilities, and distribution projects.
Please type or print legibly in ink:
WATER UTILITY
Name of Water System
CITY OF RENTON, Contact - ABDOUL GAFOUR
Name of Purveyor (Owner or System Contact)
1055 S. GRADY WAY
Mailing Address
RENTON WA 98057
City State Zip
DOH Sstem ID No.:
y
DOH Project No.:
(if applicable)
Date Construction Documents
Approved by DOH
PROJECT NAME AND DESCRIPTNE TITLE:
CHECK ONE: Entire Project Completed. ❑ Description of Portions Completed.
(If applicable)
PROFESSIONAL ENGINEER'S ACKNOWLEDGMENT (Complete items below Attach additional sheets as needed)
The undersigned professional engineer (PE), or their authorized agent, has inspected the above -described project which, as to
layout, size and type of pipe, valves and materials, reservoir and other designed physical facilities, has been constructed and is
substantially completed in accordance with construction documents reviewed by the purveyor's engineer or approved by the
Department of Health. In the opinion of the undersigned engineer, the installation, physical testing procedures, water quality tests,
and disinfection practices were carried out in accordance with state regulations and principles of standard engineering practice. KA
I have reviewed the disinfection procedures ,pressure test results ,and results of the bacteriological tests) for this project
and certify that they comply with the requirements of the construction standards/specifications approved by the Department of
Health. (Check all boxes that apply that are consistent with the nature of the project.)
This project changes the physical capacity of the system to serve consumers. The system is now able to serve 20
equivalent residential units (ERUs.) ❑Not applicable 03-21-2022
Date Signed
PACIFIC ENGINEERING DESIGN LLC
Name of Engineering Firm
GREG DIENER
Name of PE Acknowledging Construction
15445 53RD AVE S
Mailing Address
SEATTLE,k7 98188
City
Engineer'
C1
State/Federal Funding Type (if any)
Please return completed form to vour regional office checked below.
Zip
NWRO Drinlang Water ❑ SWRO Drinking Water ❑ ER( Drinking Water
Department of Health Department of Health Department of Health
20425 72°d Ave. S, Ste 310 PO Box 47823 16201 E. Indiana Ave, Suite 1500
Kent, WA 98032-2388 Olympia, WA 98504-7823 Spokane Valley, WA 99216
253-395-6750 360-236-3030 509-329-2100
For people with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-525-0127
(TDD/TTY ca11711).
The operator must attach a completed Water Facilities Inventory (WFI) form in accordance with WAC 246-290-120(6), if applicable.
Contact your regional office for WFI forms or additional Construction Completion Report forms.
DOH Form 331-121-F (01/10)