FORM CPV-1FABRICATOR’S DATA REPORT FOR COMPOSITE REINFORCED PRESSURE VESSELS (CLASS III)

(Revision A — 2017)As Required by the Provisions of the ASME Boiler and Pressure Vessel Code

1. Fabricated and Certified by(Name and Address of Fabricator)

2. Fabricated for(Name and Address of Purchaser)

3. Location Operating(Name and Address)

4. Type

(Edition and Addenda Date, if Applicable)

(National Board No.) (Year Built)

(Code Case No.)

(ID) (Length) (Thickness) (Shape)

(CRN)(Horiz. or Vertical)

5. User’s Design Specification No.

7. Qualification Report No.

8. ASME Section X

9. Service

Date6. Procedure Specification No.

14. Fabrication for MAWP psi (kPa) at Maximum Allowable Temperature

15. Minimum Allowable Temperature

(Manufacturer’s Serial No.)

(07/17)

Drawing No. Prepared by

Date Latest Requalification Date

Date

10. Restrictions and Warnings

11. Shell: Construction

12. Heads : Construction

13. Liner Construction, Thickness and Material

18. Connections or Provisions for Overpressure Relief

19. Supports and Attachments

Size and Configuration

(ID) (Attachment)

(Hydro./Pneum./Combination)

(Horizontal/Vertical) (Fluid(s) Used in the Test)

(Thickness) (Shape)

ºF (ºC)

ºF (ºC) at

Size and Configuration

psi (kPa)

17. Performed in the position using

16. Test Pressure psi (kPa) ºF (ºC)at

(National Board Authorized Inspector Number)

FORM CPV-1 (Back)(Revision A — 2017)

CERTIFICATE OF SHOP COMPLIANCE

CERTIFICATE OF SHOP INSPECTION

20. Reinforcement Type and Resin for Structural Laminate

24. Remarks

Date

Commissions

(Authorized Inspector)

(Fabricator) (Authorized Representative)

(Date),

Date

Signed

We certify that the statements in this Data Report to be correct and that all details of design, material, construction, and

workmanship of this vessel conform to the ASME BOILER AND PRESSURE VESSEL CODE, Section X.

Co. Name Signed

ExpiresRP Certification of Authorization No.

I, the undersigned, holding a valid commission issued by the National Board of Boiler and Pressure Vessel

Inspectors and/or the State or Province of and employed by

of , have inspected the vessel described in this Fabricator’s Data

Report on , , and state that, to the best of my knowledge and belief, the

Manufacturer has constructed this part in accordance with the ASME BOILER AND PRESSURE VESSEL CODE, Section X,

Class III. By signing this certificate, neither this inspector nor his employer makes any warranty, expressed or implied,

concerning the part described in this Fabricator’s Data Report. Furthermore, neither the Inspector nor his 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.

25. Year of Expiration of Vessel

23. Manufacturer’s Partial Data Reports, properly identified and signed by commissioned inspectors, have been

furnished for the following components

21. Barcol Hardness

22. Nozzles Reinforcement Purpose Size Type Material Thickness Material How Attached

(07/17)