Free nb-136.indd - Tennessee

in accordance with provisions of the National Board Inspection Code Submitted to
(name of jurisdiction) (address)

REPLACEMENT OF STAMPED DATA FORM

Submitted by
(name of owner.) (address)

(telephone no.)

(telephone no.)

1. 2. 3. 4. 5. 6. 7. 8.

Manufactured by Manufactured for

(name and address) (name and address) (address)

Location of installation Date installed Previously installed at

Manufacturer's Data Report attached Item registered with National Board Item identification Type Mfg. serial no. MAWP psi

No No

Yes Yes, NB Number Year built Dimensions Jurisdiction no.

Safety relief valve set at

psi

9.

Complete the reverse side of this report with a true facsimile of the legible portion of the nameplate.

10. If nameplate is lost or illegible, documentation shall be attached identifying the object to the Manufacturer's Data report referenced on this form. 11. I request authorization to replace the stamped data and/or nameplate on the above described pressure-retaining item in accordance with the rules of the National Board Inspection Code (NBIC), Part RB-1030. Owner's name Signature Title 12. Authorization is granted to replace the stamped data or to replace the nameplate of the above described pressure-retaining item. Signature Jurisdiction
This form may be obtained from The National Board of Boiler and Pressure Vessel Inspectors, 1055 Crupper Ave., Columbus, OH 43229 NB-136 Rev.5
(chief inspector or authorized representative)

Date

Date

The following is a true facsimile of the legible portion of the item's nameplate. (Please print. Where possible, also attach a rubbing of the nameplate.)

I certify that to the best of my knowledge and belief, the statements in this report are correct, and that the replacement information, data, and identification numbers are correct and in accordance with provisions of the National Board Inspection Code, Part RB-1030. Attached is a facsimile or rubbing of the stamping or nameplate. Name of Original Manufacturer Signature
(authorized representative)

Date Expires

Certificate of Authorization No.

Witnessed by Signature

(name of inspector)

Employer Date Commissions

(inspector)