SEWS 8.1.9 (1 of 4) Sheet 1 of \_\_\_\_\_\_

+------------------------------------+----------------+---------------+---+
| **SCREENING EVALUATION WORK SHEET  |                |               |   |
| (SEWS)**                           |                |               |   |
+------------------------------------+----------------+---------------+---+
| **Equipment ID No.:**              | **Equipment    |               |   |
|                                    | Class:         |               |   |
|                                    | Instruments on |               |   |
|                                    | Racks**        |               |   |
+------------------------------------+----------------+---------------+---+
| Equipment description:             |                |               |   |
+------------------------------------+----------------+---------------+---+
| Equipment Location: Bldg.          | Floor El.      | Room,         |   |
|                                    |                | Row/Col.      |   |
+------------------------------------+----------------+---------------+---+
| Manufacturer, model, etc.:         |                |               |   |
+------------------------------------+----------------+---------------+---+
| Weight:                            |                |               |   |
+------------------------------------+----------------+---------------+---+
| Drawing No.:                       | Performance    |               |   |
|                                    | Category:      |               |   |
+------------------------------------+----------------+---------------+---+
| ***Functionality Requirement***    |                |               |   |
+------------------------------------+----------------+---------------+---+
| q Contact Lead Relay Reviewer to   |                |               |   |
| determine if item contains         |                |               |   |
| Essential Relays                   |                |               |   |
|                                    |                |               |   |
| q For components whose function or |                |               |   |
| structural integrity is required,  |                |               |   |
| complete all sections of this      |                |               |   |
| form.                              |                |               |   |
|                                    |                |               |   |
| q For all other components, only   |                |               |   |
| anchorage evaluation is required.  |                |               |   |
+------------------------------------+----------------+---------------+---+
| ***Seismic Capacity vs. Demand     |                |               |   |
| (Chapter 5)***                     |                |               |   |
+------------------------------------+----------------+---------------+---+
| 1\. Seismic Capacity based on:     |                |               |   |
|                                    |                |               |   |
| q Reference Spectrum               |                |               |   |
|                                    |                |               |   |
| q GERS                             |                |               |   |
|                                    |                |               |   |
| q Existing documentation           |                |               |   |
|                                    |                |               |   |
| 2\. Elevation where equipment      |                |               |   |
| receives seismic input             |                |               |   |
|                                    |                |               |   |
| Seismic Demand Spectrum (SDS)      |                |               |   |
| based on:                          |                |               |   |
|                                    |                |               |   |
| q In-structure response spectrum   |                |               |   |
| (IRS) per DOE-STD-1020             |                |               |   |
|                                    |                |               |   |
| q Other in-structure response      |                |               |   |
| spectrum (determine appropriate    |                |               |   |
| experience data                    |                |               |   |
|                                    |                |               |   |
| scale factor)                      |                |               |   |
|                                    |                |               |   |
| q Design basis earthquake (DBE)    |                |               |   |
| per DOE-STD-1020                   |                |               |   |
|                                    |                |               |   |
| q Other                            |                |               |   |
|                                    |                |               |   |
| Scale Factor (SF) Experience Data  |                |               |   |
| Factor (F~ED~)                     |                |               |   |
|                                    |                |               |   |
| Does capacity exceed demand? Y N U |                |               |   |
|                                    |                |               |   |
| Reference:                         |                |               |   |
+------------------------------------+----------------+---------------+---+
| ***Caveats (Section 8.1.9)***      |                |               |   |
+------------------------------------+----------------+---------------+---+
| *Reference Spectrum* (Identify     |                |               |   |
| with an asterisk (\*) those        |                |               |   |
| caveats which are met by intent    |                |               |   |
| without meeting the specific       |                |               |   |
| wording of the caveat rule and     |                |               |   |
| explain the reason for this        |                |               |   |
| conclusion in the COMMENTS section |                |               |   |
| below)                             |                |               |   |
+------------------------------------+----------------+---------------+---+
| 1\. Equipment is included in       |                |               |   |
| earthquake experience equipment    |                |               |   |
| class Y N U N/A\                   |                |               |   |
| 2. No computers or programmable    |                |               |   |
| controllers Y N U N/A\             |                |               |   |
| 3. Steel frame and sheet metal     |                |               |   |
| structurally adequate Y N U N/A\   |                |               |   |
| 4. Adjacent racks which are close  |                |               |   |
| enough to impact, or sections\     |                |               |   |
| of multi-bay racks, are bolted     |                |               |   |
| together if they contain\          |                |               |   |
| essential relays Y N U N/A\        |                |               |   |
| 5. Have you looked for and found   |                |               |   |
| no other adverse concerns? Y N U   |                |               |   |
| N/A\                               |                |               |   |
| \                                  |                |               |   |
| Is the intent of all the caveats   |                |               |   |
| met for Reference Spectrum? Y N U  |                |               |   |
| N/A                                |                |               |   |
+------------------------------------+----------------+---------------+---+
| SEWS 8.1.9 (2 of 4) Sheet 2 of     |                |               |   |
| \_\_\_\_\_\_                       |                |               |   |
|                                    |                |               |   |
| **SCREENING EVALUATION WORK SHEET  |                |               |   |
| (SEWS) (Cont.)**                   |                |               |   |
+------------------------------------+----------------+---------------+---+
| **Equipment ID No.:**              | **Equipment    |               |   |
|                                    | Class:         |               |   |
|                                    | Instruments on |               |   |
|                                    | Racks**        |               |   |
+------------------------------------+----------------+---------------+---+
| Equipment description:             |                |               |   |
+------------------------------------+----------------+---------------+---+
| ***Caveats (Cont.)***              |                |               |   |
+------------------------------------+----------------+---------------+---+
| *GERS* (Identify with an asterisk  |                |               |   |
| (\*) those caveats which are met   |                |               |   |
| by intent without meeting the      |                |               |   |
| specific wording of the caveat     |                |               |   |
| rule and explain the reason for    |                |               |   |
| this conclusion in the COMMENTS    |                |               |   |
| section below)                     |                |               |   |
+------------------------------------+----------------+---------------+---+
| 1\. Equipment is included in       |                |               |   |
| generic seismic testing equipment  |                |               |   |
| class Y N U N/A\                   |                |               |   |
| 2. Meets all Reference Spectrum    |                |               |   |
| caveats Y N U N/A\                 |                |               |   |
| 3. Component is a pressure,        |                |               |   |
| temperature, level or flow         |                |               |   |
| transmitter Y N U N/A\             |                |               |   |
| 4. Component is one of the         |                |               |   |
| specific makes and models tested Y |                |               |   |
| N U N/A\                           |                |               |   |
| 5. Necessary function of component |                |               |   |
| not sensitive to seismically\      |                |               |   |
| induced system perturbations       |                |               |   |
| (e.g., sloshing) Y N U N/A\        |                |               |   |
| 6. No vacuum tubes Y N U N/A\      |                |               |   |
| 7. All external mounting bolts in  |                |               |   |
| place Y N U N/A\                   |                |               |   |
| 8. Demand based on amplified       |                |               |   |
| portion of 3% damped floor         |                |               |   |
| response\                          |                |               |   |
| spectrum if estimated natural      |                |               |   |
| frequency of rack less than 33     |                |               |   |
| Hertz Y N U N/A\                   |                |               |   |
| 9. Rack capable of structurally    |                |               |   |
| transferring GERS level seismic\   |                |               |   |
| loads to anchorage Y N U N/A\      |                |               |   |
| 10. Adjacent racks which are close |                |               |   |
| enough to impact, or sections of\  |                |               |   |
| multi-bay racks, are bolted        |                |               |   |
| together Y N U N/A\                |                |               |   |
| \                                  |                |               |   |
| Is the intent of all the caveats   |                |               |   |
| met for GERS? Y N U N/A            |                |               |   |
+------------------------------------+----------------+---------------+---+
| ***Anchorage (Chapter 6)***        |                |               |   |
+------------------------------------+----------------+---------------+---+
| 1\. Type of anchorage:             |                |               |   |
|                                    |                |               |   |
| q expansion anchor                 |                |               |   |
|                                    |                |               |   |
| q cast-in-place bolt or headed     |                |               |   |
| stud anchor                        |                |               |   |
|                                    |                |               |   |
| q cast-in-place J-bolt             |                |               |   |
|                                    |                |               |   |
| q grouted-in-place bolt            |                |               |   |
|                                    |                |               |   |
| q welds to embedded steel on       |                |               |   |
| exposed steel                      |                |               |   |
|                                    |                |               |   |
| q lead cinch anchors               |                |               |   |
|                                    |                |               |   |
| q Other                            |                |               |   |
|                                    |                |               |   |
| q N/A (no further anchorage        |                |               |   |
| considerations)                    |                |               |   |
|                                    |                |               |   |
| 2\. Appropriate characteristics    |                |               |   |
| for anchorage type checked         |                |               |   |
|                                    |                |               |   |
| (size, location, equipment         |                |               |   |
| characteristics) Y N U             |                |               |   |
|                                    |                |               |   |
| 3\. Gap at threaded anchor less    |                |               |   |
| than 1/4 inch Y N U N/A            |                |               |   |
|                                    |                |               |   |
| 4\. Base stiffness and no          |                |               |   |
| significant prying action          |                |               |   |
| requirements met Y N U             |                |               |   |
|                                    |                |               |   |
| 5\. Equipment base strength and    |                |               |   |
| structural load path adequate Y N  |                |               |   |
| U                                  |                |               |   |
|                                    |                |               |   |
| 6\. Embedment steel and pads       |                |               |   |
| requirements met Y N U N/A         |                |               |   |
|                                    |                |               |   |
| 7\. Embedment length requirements  |                |               |   |
| met Y N U                          |                |               |   |
|                                    |                |               |   |
| 8\. Anchor spacing requirements    |                |               |   |
| met Y N U                          |                |               |   |
|                                    |                |               |   |
| 9\. Edge distance requirements met |                |               |   |
| Y N U                              |                |               |   |
|                                    |                |               |   |
| 10\. Concrete strength             |                |               |   |
| requirements met Y N U             |                |               |   |
+------------------------------------+----------------+---------------+---+

SEWS 8.1.9 (3 of 4) Sheet 3 of \_\_\_\_\_\_

+------------------------------------+---------------------------------+
| **SCREENING EVALUATION WORK SHEET  |                                 |
| (SEWS) (Cont.)**                   |                                 |
+------------------------------------+---------------------------------+
| **Equipment ID No.:**              | **Equipment Class: Instruments  |
|                                    | on Racks**                      |
+------------------------------------+---------------------------------+
| Equipment description:             |                                 |
+------------------------------------+---------------------------------+
| ***Anchorage (Cont.)***            |                                 |
+------------------------------------+---------------------------------+
| 11\. Concrete crack requirements   |                                 |
| met Y N U                          |                                 |
|                                    |                                 |
| 12\. Equipment with essential      |                                 |
| relays requirements met Y N U N/A  |                                 |
|                                    |                                 |
| 13\. Installation adequacy         |                                 |
| requirements met Y N U N/A         |                                 |
|                                    |                                 |
| 14\. No other concerns Y N U       |                                 |
|                                    |                                 |
| Does anchorage capacity exceed     |                                 |
| demand? Y N U                      |                                 |
|                                    |                                 |
| Reference:                         |                                 |
+------------------------------------+---------------------------------+
| ***Interaction Effects (Chapter    |                                 |
| 7)***                              |                                 |
+------------------------------------+---------------------------------+
| 1\. Soft targets free from impact  |                                 |
| by nearby equipment\               |                                 |
| or structures Y N U N/A\           |                                 |
| 2. If equipment contains sensitive |                                 |
| essential relays, equipment free\  |                                 |
| from all impact by nearby          |                                 |
| equipment or structures Y N U N/A\ |                                 |
| 3. Attached lines have adequate    |                                 |
| flexibility Y N U N/A              |                                 |
|                                    |                                 |
| 4\. No collapse of overhead        |                                 |
| equipment, distribution systems,\  |                                 |
| or masonry walls Y N N/A\          |                                 |
| 5. Equipment is free from credible |                                 |
| and significant\                   |                                 |
| seismic-induced flood and spray    |                                 |
| concerns Y N N/A\                  |                                 |
| 6. No credible seismic-induced     |                                 |
| fire concerns Y N N/A              |                                 |
|                                    |                                 |
| 7\. No other "two over one"        |                                 |
| concerns as defined in             |                                 |
| DOE-STD-1021 Y N N/A               |                                 |
|                                    |                                 |
| 8\. No other concerns Y N U N/A    |                                 |
|                                    |                                 |
| Is equipment free of interaction   |                                 |
| effects? Y N U                     |                                 |
+------------------------------------+---------------------------------+
| ***Comments***                     |                                 |
+------------------------------------+---------------------------------+
|                                    |                                 |
+------------------------------------+---------------------------------+

SEWS 8.1.9 (4 of 4) Sheet 4 of \_\_\_\_\_\_

+-------------------------------+-----------------------------+--------+
| **SCREENING EVALUATION WORK   |                             |        |
| SHEET (SEWS) (Cont.)**        |                             |        |
+-------------------------------+-----------------------------+--------+
| **Equipment ID No.:**         | **Equipment Class:          |        |
|                               | Instruments on Racks**      |        |
+-------------------------------+-----------------------------+--------+
| Equipment description:        |                             |        |
+-------------------------------+-----------------------------+--------+
| ***Comments (Cont.)***        |                             |        |
+-------------------------------+-----------------------------+--------+
| Screening Walkdown(s):        |                             |        |
|                               |                             |        |
| [Date]{.underline}            |                             |        |
| [Time]{.underline} [Team      |                             |        |
| Members]{.underline}          |                             |        |
+-------------------------------+-----------------------------+--------+
| ***Recommend Resolution***    |                             |        |
+-------------------------------+-----------------------------+--------+
| q Maintenance action:         |                             |        |
|                               |                             |        |
| q Further evaluation:         |                             |        |
|                               |                             |        |
| q Retrofit design:            |                             |        |
|                               |                             |        |
| q Other:                      |                             |        |
|                               |                             |        |
| q No further action required. |                             |        |
| Equipment is seismically      |                             |        |
| adequate.                     |                             |        |
+-------------------------------+-----------------------------+--------+
| All aspects of the            |                             |        |
| equipment\'s seismic adequacy |                             |        |
| have been addressed.          |                             |        |
|                               |                             |        |
| Evaluation by: Date:          |                             |        |
|                               |                             |        |
| (All team members)            |                             |        |
+-------------------------------+-----------------------------+--------+