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Department of Health Construction Completion Report Form [Water Distribution Only]DOH Form 331-146 (Updated 08/10) Construction Completion Report Form for Submittal Exception Process In accordance with WAC 246-290-120(5), a Construction Completion Report Form is required for all approved construction projects. Purveyors must submit a Construction Completion Report to the Department of Health (DOH) within sixty (60) days of completion and before use of any water system facility. This includes any storage tank and booster pump facilities reviewed under the submittal exception process as provided by WAC 246-290- 125(3). Under the submittal exception process for other distribution-related facilities (including distribution main projects), designed by a professional engineer but not submitted to DOH for approval, the report does not need to be submitted. However, the purveyor must keep the Construction Completion Report on file and make it available for review upon request by DOH in accordance with WAC 246-290-125 (2)(b) and WAC 246-290-125(3)(f). Furthermore: (1) The report form must bear the seal, date and signature of a professional engineer (PE) licensed in the state of Washington; (2) If project construction is being completed in stages, attach a description of the portion of the project being completed as approved that is acknowledged by a PE on the date given below; (3) As future portions of staged construction projects are completed, each must be acknowledged by a PE; and (4) Per WAC 246-290-120(5)(c), the amount of change in the physical capacity of a system must be documented, if the project results in a change in physical capacity. Please type or print legibly in ink: _____________________________________ DOH System ID No.:__________________ Name of Water System _____________________________________ Name of Purveyor (Owner or System Contact) _____________________________________ Date WSP Approved by DOH___________ Mailing Address _____________________________________ City State Zip Type of Project (check all that apply): (Project must be identified in the CIP of the Water System Plan) Booster Pump Station(s) - If checked send form to DOH Reservoir and Storage Tank(s) – If checked send form to DOH Pressure Tank(s) Internal Tank Coating Transmission Main(s) Other (specify): For project reports and construction documents that have not been reviewed by DOH, provide name of PE who completed Engineering Design Review Report Form (a departmental form): ______________________________________ Name of PE Shown as Review Engineer city of renton 71850L george stahl 3555 ne 2nd street Renton WA 98056 9/19/2013 X distribution main(s) DOH Form 331-146 (Updated 08/10) Project Name and Descriptive Title: Check one: Entire Project Completed. Description of Portions Completed. Complete (Attach additional sheets as needed): Professional Engineer’s Acknowledgment 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 DOH. 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. I have reviewed the disinfection procedures , pressure test results , and results of the bacteriological test(s) for this project and certify that they comply with the requirements of the construction standards/specifications approved by the DOH. (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 equivalent residential units (ERUs.) Not applicable _________________________________ Name of Engineering Firm** _________________________________ Name of PE Acknowledging Construction _________________________________ Mailing Address** PE’s Seal _________________________________ City State Zip** ____________________________________ **Complete if PE acknowledging construction Engineer’s Signature Date completion is not employed directly by water system. Please return completed form to DOH regional office checked below if the project is for new storage tanks or booster pump stations. For all other distribution related projects, please maintain on file. Northwest Drinking Water Department of Health 2045 72nd Ave S, Suite  Kent, WA 98032-2358 Phone: (253) 395-6750 Fax: (253) 395-6760 Southwest Drinking Water Department of Health PO Box 47823 Olympia, WA 98504-7823 Phone: (360) 236-3030 Fax: (360) 664-8058 Eastern Drinking Water Department of Health 16201 E Indiana Ave, Suite 1500 Spokane Valley, WA 99216 Phone: (509) 329-2100 Fax: (509) 329-2104 The purveyor must attach a completed Water Facilities Inventory (WFI) form in accordance with WAC 246- 290-120(6), if applicable. Contact the regional office in your area for WFI forms or additional Construction Completion Report forms. ,I\RXQHHGWKLVSXEOLFDWLRQLQDQDOWHUQDWHIRUPDWFDOO  )RU77<7''FDOO