STATE OF TENNESSEE
DEPARTMENT OF LABOR BOILER & ELEVATOR INSPECTION DIVISION 220 FRENCH LANDING DRIVE NASHVILLE, TN 37243
Application for Permission to Re-install a Second-hand Boiler Formerly Operated in this State or of Standard Construction Equivalent to Tennessee State and so Stamped, Formerly Operated in Another State. This application must be made by owner or user, or prospective owner or user of boiler, and the words "owner or user" in this section shall not be construed to mean manufacturer or seller of a boiler. See Rule No. 0800-3-3-.03(18)
GIVE THE FOLLOWING DETAILED INFORMATION
CODE SYMBOL STAMPING
NATIONAL BOARD NUMBER
1. Name of new Company or Idividual desiring to install boiler
(Print plainly)
2. Business address 3. Where is boiler to be located if allowed to be installed?__
(City, Town, Village) (County)
4. Present Location of boiler 5. Date boiler will be ready for inspection 6. By whom was the boiler last owned before being purchased by you?
(Do not give DEALER'S NAME)
7. If stationary, location when lasted used? 8. Was boiler ever inspected under the Boiler Code of Tennessee? 9. Date of such inspection_________________________If certificate was issued, give following: 10.Tennessee State boiler number 11. Type of boiler Certificate issued by Built by New Owner Signature New Owner Business Address Pressure
(insurance company)
Yr
NOTE: Unless the above questions are clearly answered, this application will not be accepted. If possible, forward last inspection report or certificate of inspection with application. Boilers, the construction of which are not equal to the construction specified in the Tennessee State Boiler Code, will not be allowed to come into this State. See Tennessee State Boiler Code.
LIST ALL STAMPING (APPEARING ON BOILER FRONT) ON REVERSE SIDE OF REPORT
Mail Copy to: Tennessee Department of Labor Boiler & Elevator Division 710 James Robertson Pkwy. Andrew Johnson Twr., Third Floor Nashville, Tn. 37243-0663
STATE OF TENNESSEE DEPARTMENT OF LABOR DIVISION OF BOILER AND ELEVATOR INSPECTION
TIME & DATE COMPANY RECEIVING SERVICE MAILING ADDRESS PERSON CONTACTED QC NUCLEAR SURVEY SPECIAL INSPECTION TYPE OF ITEM INSP N.B. NUMBER TENN NUMBER SERIAL NUMBER FIT UP QC SHOP REVIEW TITLE SHOP INSPECTION TO TIME & DATE
FINAL HYDRO
SPECIAL HYDRO
TRAVEL
MILES
$ $ $ $ $ days
SIGNATURE
AIRLINES (credit card/not on expense account) LODGING SUBSISTENCE NIGHTS Days
MISCELLANEOUS (taxi, parking, telephone, etc.) FEES FOR SERVICE INSPECTOR
NAME
$
TOTAL: $ NOTE: Include TENN Number and N.B. number where applicable, attach copies of Data Sheets, Second Hand Application, special Inspection Reports, Accident Reports, Memorandum report of trip, etc.; as an aid to ascertain true liability of claim for invoice. APPROVED FOR INVOICE
Donald E. Tanner Chief Boiler Inspector State of
LB-0128 (Rev. May 1994)