175650 FORM U-1A MANUFACTURER'S DATA REPORT FOR PRESSURE VESSELS

(Alternative Form for Single Chamber, Completely Shop or Field Fabricated Vessels Only)
SO #

As Required by the Provisions of the ASME Boiler and Pressure Vessel Code Rules, Section VIII, Division 1 Page 1 of 2
110413
PO REF.

1. Manufactured and certified by Rush, Certified, Inc., 1514 Rochester Street, Lima, New York, 14485
(Name and address of Manufacturer)
2. Manufactured for Filter-Mart Corporation, P.O. Box 1327, Cookeville, Tennessee, 38503
(Name and address of Purchaser)
3. Location of Installation Unknown
(Name and address)

Vertical 5027 to 5028 n/a RC-0735 R-3 5027-5028 2018

(Horizontal or vertical, tank) (Manufacturer's serial number) (CRN) (Drawing number) (National Board number) (Year built)
4. Type

5. ASME Code, Section VIII, Division 1 2017/ N/A N/A N/A

[Edition and Addenda, if applicable (date)] (Code Case numbers) [Special service per UG-120(d)]

6. Shell: SA 106 C .375 in 0 in 12" (ID) 42.375"

(Material spec. number, grade) (Nominal thickness) (Corr. allow.) (Inner diameter) [Length (overall)]
Body Flanges on Shells
Bolting
Flange How
No. Type ID OD Min Hub Thk Material Location Washer (OD, ID, Washer
Thk Attached Num & Size Bolting Material
thk) Material
1 12" CL-300 RFSO 12.88" 20.5" 2" 0.875" SA 105 Welded Top 16 - 1-1/8" SA 193 B7, SA 194 2H n/a n/a
7. Seams: Type S n/a 70% n/a n/a Type 1 n/a 70% 1
[Long. (welded, dbl., sngl., lap, butt)] [R.T.(spot or full)] (Eff.,%) (H.T. temp) (Time, hr) [Girth. (welded, dbl., sngl., lap, butt)] [R.T. (spot or full)] (Eff., %) (No. of courses)
8. Heads: (a) Material (b) Material
SA 105
(Spec. no., grade) (Spec. no., grade)
SA 234 WPB

Location (Top, Bottom, Minimum Corrosion Crown Radius Knuckle Radius Elliptical Ratio Conical Apex Hemispherical Flat Side to Pressure (Convex or
Ends) Thickness Allowance Angle Radius Diameter Concave)
(a) TOP 2" 0" N/A N/A N/A N/A N/A 20.5" N/A
(b) BOTTOM .500" 0" N/A N/A 2:1 N/A N/A N/A Concave

Body Flanges on Heads

Min Hub
Type ID OD Flange Thk Material How Attached
Bolting

Thk
Location Num & Size Bolting Material
Washer (OD,
Washer Material
ID, thk)
(a) N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
9. MAWP 740 psi N/A at max. temp. 100 °F N/A
(Internal) (External) (Internal) (External)
Min. design metal temp. -20 °F at 740 psi . Hydro, pneu., or comb. test pressure HYDRO at 1110 psi .

Proof test N/A .

10. Nozzles, inspection and safety valve openings:

Purpose (Inlet, Outlet, Diameter or Material Nozzle Thickness Reinforcement Attachment Details Location (Insp.
No. Type
Drain, etc.) Size Nozzle Flange Nom. Corr. Material Nozzle Flange Open.)
Inlet 1 6" CL-300 RFSO SA 106C SA 105 .432 0" - UW-16.1(c) UW-21(1) Shell
Outlet 1 6" CL-300 RFSO SA 106C SA 105 .432 0" - UW-16.1(c) UW-21(1) Shell
Vent 1 1/2" NPT Coupling SA 105 - 3000# 0" - UW-16.1(a) - Head (a)
Drain 1 1/2" NPT Coupling SA 105 - 3000# 0" - UW-16.1(a) - Head (b)
Gage 2 1/4" NPT Coupling SA 105 - 3000# 0" - UW-16.1(a) - Nozzle

11. Supports: Skirt no Lugs no Legs 3 Other n/a Attached Head(b), Welded
(Yes or no) (Number) (Number) (Describe) (Where and how)
12. Remarks: Manufacturer's Partial Data Reports properly identified and signed by Commissioned Inspectors, have been furnished for the following items of the report:
N/A
(Name of part, item number, Manufacturer's name and identifying stamp)
(1) Relief valve provided by user per UG-125.
(2) Hydro test @ 1.5 times allowed per UG-99 (c)&(d).
(3) Exempt from impact testing per: UCS-66(a).
(4) Hydro test performed in the vertical position.
(5) Corrosion allowances not provided by the user or designated agent.
 FORM U-1A Page 2 of 2

Manufactured by Rush, Certified, Inc., 1514 Rochester Street, Lima, New York, 14485
Manufacturer's Serial No. 5027 to 5028 CRN n/a National Board No. 5027-5028

CERTIFICATE OF SHOP/FIELD COMPLIANCE

We certify that the statements made in this report are correct and that all details of design, material, construction, and workmanship of this vessel
conform to the ASME BOILER AND PRESSURE VESSEL CODE, Section VIII, Division 1. "U" Certificate of Authorization Number 29292
expires November 8, 2020 .
Date 01/24/2018 Co. name Rush, Certified, Inc. Signed
(Manufacturer) (Representative)
CERTIFICATE OF SHOP/FIELD INSPECTION

Vessel constructed by Rush, Certified, Inc. at 1514 Rochester Street, Lima, New York, 14485
I, the undersigned, holding a valid commission issued by The National Board of Boiler and Pressure Vessel Inspectors and employed by
The Hartford Steam Boiler Inspection and Insurance Company, of Hartford, CT
have inspected the component described in this Manufacturer's Data Report on January 25, 2018 ,
and state that, to the best of my knowledge and belief, the Manufacturer has constructed this pressure vessel in accordance with ASME BOILER
AND PRESSURE VESSEL CODE, Section VIII, Division 1. By signing this certificate neither the Inspector nor his/her employer makes any
warranty, expressed or implied, concerning the pressure vessel described in this Manufacturer's Data Report. Furthermore, neither the Inspector
nor his/her employer shall be liable in any manner for any personal injury or property damage or a loss of any kind arising from or connected with
this inspection.

Date 01/25/2018 Signed Commissions 16159

(Authorized Inspector) (National Board Authorized Inspector Commission number)

2960873 exe: v6.3.19 Form and version: U1A-19