gGEORGIA DEPARTMENT OF LABOR BOILER/HEATER/PRESSURE VESSEL

Michael L. Thurmond, Commissioner

REPORT OF INSPECTION
Safety Engineering Division
Jurisdiction Number Inst.Permit Number Last Inspection This Inspection Type of Inspection
In.Perm.-Initial In.Perm.-Spec.

Insp.Passed Cert.Issued Last Cert.Expires This Cert.Expires Reg.Operating Follow-up

Yes No Yes No

Send Cert. to: Out of Service Auth.Current

Own. Loc. Billing Yes Eff.Dte. Yes ID:
Bill For: Cert. Only Insp. Only
Both Spec. Amt.: Rsn.: No Rsn.:
Assigned Inspector Ins. Yes No Canc. Ins.Co./Policy
Canc.Eff.Dte.

Specific Location of Equipment Location County Type of Business

Location Billing Own. Loc. Billing:

.
Name Name
Street Street
Extra Addr. Extra Addr.
City,St.,Zip
make
City,St.,Zip
Attn.: Attn.:
Telephone: Fax: Telephone: Fax:
Owner Contact Name:
Name Contact Telephone:
Street Insp.Performed Nat'l.Board or Serial No.
Extra Addr. Int. Ext. Both
City,St.,Zip Controls Checked ASME Code Stamp
Attn.: No
Yes Yes No
Telephone: Fax: Expl.: Expl.:

Year Built Manufacturer Boiler HP LP HLW

Class
Boiler Type FT WT CI Coil Boiler Use Proc. St. Ht.Wtr.Ht.
Elec.Blr. Other Expl.: Ht.Wtr.Sp. Other Expl.:
Boiler Fuel Gas Oil Elec. Coal Boiler Capacity BTU or LBS/HR MAWP
Wood Other Expl.:
Pressure Air Cold Wtr Hot Wtr Oxygen Heat Exch.
Pressure Proc. Storage Service
Vessel Type Vessel Use
Nitrogen Autoclve Other Expl.: Other Expl.:
No. of Safety Valves Safety Valve 1 Setting Total Safety Valve Capacity Boiler 31-50
30 or less 51-100
Horsepower
101-200 201 or more
Equipment Notes

Conditions/Violations / Explanation/Required Action / Compliance Date

Inspection Narration

Signature of Inspector Signature of Person Contacted

Neither this inspection nor any provision of this inspection shall be construed to place any liability on the State of Georgia, the Inspection Agency/Company or the inspector with respect to any
claim by any person, firm or corporation relating in anyway whatsoever to Boiler Inspections and any injury or damage arising therefrom.
Send Copy to: Own. Loc. Billing doDOL-4204 (R-00)