Boiler and Pressure Vessels Repair and Alteration Report Form 1060

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505 - 6th Street, Suite 200, New Westminster, British Columbia, V3L 0E1
Local Phone: 778-396-2000 Local Fax: 778-396-2174 Toll Free: 1-866-566-SAFE (7233) Toll Free Fax: 778-396-2174
The information on this form is collected to administer the provisions of the Safety Standards Act. If you have questions about the collection, use or disclosure of this information, contact the Records, Information & Privacy Analyst at 1-866-566-SAFE (7233).
B.C. ID #: _____________ OWNER EQUIP. #: ____________
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1. Name and Address of Organization doing Repair/Alteration ____________________________________________ _______________________________________________ BCSA License No. & Expiry Date ____________ Location of Installation____________________________________________________________________________ 2. Name of Owner __________________________________________________________________________________ Address ________________________________________________________________________________________ 3. Boiler/Pressure Vessel Description ________________________________ Manufacturer’ s Name __________________________________________ 4. Design Conditions: a) Vessel/Shellside/Boiler: b) Jacket/Tubeside: Max Allowable Working Press. _____ PSI Min/Max Design Temp ____/____oF Max Allowable Working Press. _____ PSI Min/Max Design Temp ____/____oF CRN ______________________ Serial No. __________________
5. Description of Defects: (Location and types of deterioration that resulted in the repair/alteration):____________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 6. ASME Code Edition and Addenda used for work: ASME Sect. __________ Year ________ Addenda _______ 7. Repair/Alteration Description of Work. (Step by step description of repair/alteration method. Attach additional sheets as needed). Note 1: Repair/Alteration Procedure to be accepted by BCSA Boiler Safety Officer prior to start of work.
8. Material – List any material used in repair/alteration and any base material welded on:
Item Shell/Drum Tubesheet Nozzles Material Specifications Thick/Sch Diameter Item Heads/Ends Tubes Flanges/Fitting Class Material Specifications Thick/Sch Diameter
9. Welding Procedure – British Columbia Registration Number WP-_________ 10.Heat Treatment: Bake Out (Temp./Time) ____/____hr 11.Non Destructive Examination (Specify type and extent).
WPS Numbers used: ________
Preheat Temp. ______ Post Weld HT (Temp./Time) _____/____
FRM-1060-02 (2009-05-01)
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B.C. ID #: _____________ 12.Pressure Test a) b) Hydrostatic Other Test Vessel/Boiler/Shellside PSI
OWNER EQUIP. #: _________ ___ Tubeside/Jacket PSI
13. Welded Replacement Parts: Attached are Manufacturer’s Partial Data Reports or Repair/Alteration Reports properly identified and signed by Authorized Inspectors for the following items of this report: (Welded parts supplied by others).
14.Responsibility Owner/Client. Identify below items that the owner/client has assumed responsibility for Note (2)
a) d) Design Submission ___________ Welding Control __________ b) Repair/Alteration Procedure: _________ c) Material Control ____________ g) Pressure Test __________ e) NDE __________ f) Heat Treatment __________
Note 2: Owner/Client must have a valid B.C. Contractors License for the Scope of Work to assume responsibility for function c, d, e, f, or g. 15. REMARKS:
We certify that the statements made in this Report are correct and that all design, material, construction and workmanship on this repair/alteration conform to the requirements of the Power Engineers, Boiler, Pressure Vessel and Refrigeration Safety Regulation: a) For all items except for items identified in 14: b) For items identified in 14 only:
Repair/Alteration Organization Name B.C. License Number and Expiry Date Signature and Date Print Name Owner/Client Organization Name B.C. License Number and Expiry Date Signature and Date Print Name
17. DATE WORK WAS COMPLETED: _____________________________ 18. a) CERTIFICATE OF INSPECTION I have inspected the repairs and/or alterations described in this report. To the best of my knowledge this work has been done in accordance with the Power Engineers, Boiler, Pressure Vessel and Refrigeration Safety Regulation. BCSA Boiler Safety Officer (when work is inspected by BCSA)
BCSA Boiler Safety Officer Signature and Date Print Name
Report Received by BCSA Boiler Safety Officer
FRM-1060-02 (2009-05-01)
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