FORM NV-1 CERTIFICATE HOLDER’S DATA REPORT FOR PRESSURE OR VACUUM RELIEF VALVES*

As Required by the Provisions of the ASME Code, Section III, Division 1

(07/17)

Pg. 1 of

1. Manufactured and certified by

2. Manufactured for

3. Location of installation

4. Valve Orifice size Nom. inlet size Outlet size

at 6. Type

7. Identification

8. Control ring settings

9. Pressure-retaining items

10. Relieving capacity overpressure as certified by the National Board @

11. Remarks

Design Specification certified by

Date

NV Certificate of Authorization No. Expires

Name Signed

Design Report certified by P.E. State

CERTIFICATION OF DESIGN

CERTIFICATE OF COMPLIANCE

P.E. State Reg. no.

Reg. no.

Body

Bonnet or Yoke

Support Rods

Nozzle

Disk

Spring Washers

Adjusting Screws

Spindle

Spring

Bolting

Other Items

Serial No. or Identification

* Supplemental information in the form of lists, sketches, or drawings may be used provided: (1) size is 81/2 � 11; (2) information in items 1 through 4 on this DataReport is included on each sheet; and (3) each sheet is numbered and the number of sheets is recorded at the top of this form.

(name and address of NV Certificate Holder)

(name and address of Purchaser)

(name and address)

5. ASME Code, Section III, Division 1

Material Spec., Including Type or Grade Tensile Strength

(CRN) (National Bd. no.) (year built) (drawing no.)

(authorization representative) (NV Certificate Holder)

(Cert. Holder’s serial no.)

(edition)

(model no., series no.)

(set pressure)

(steam or fluid)

(spring, pilot, or power operated) (blowdown) (rated temp.) (hydro. test., inlet)

[Addenda (if applicable) (date)] (class) (Code Case no.)

We certify that the statements made in this report are correct and that this valve conforms to the rules for construction of the ASME Code, Section III, Division 1.

(date)

FORM NV-1 (Back — Pg. 2 of )

Certificate Holder’s Serial No.

Commission (Authorized Nuclear Inspector) [National Board Number and Endorsement]

Signed Date

(07/11)

state that to the best of my knowledge and belief, the Certificate Holder has constructed this valve in accordance with the ASME Code, Section III, Division 1. By signing this certificate neither the inspector nor his employer makes any warranty, expressed or implied, concerning the component described in this 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.

CERTIFICATE OF INSPECTION

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

of have inspected the valve described in this Data Report on and