APPLICATION FOR NATIONAL BOARD “VR” CERTIFICATE OF AUTHORIZATION TO REPAIR PRESSURE RELIEF VALVES

The company named below hereby makes application for:

� New Issuance � Renewal � Name Change � Location Change � Scope Change Company Name: ____________________________________________________________________________________ (Full company name exactly as it should appear on your Certificate of Authorization) Previous Name: ______________________________________________________________________________________

(If applicable) Nameplate Abbreviation: _____________________________________________________________________________

(If applicable)

Plant Location: (Exactly as it should appear on your Certificate)

Mailing Address:

Previous Location: ____________________________________________________________________________________

(If applicable)

and attests that it can repair pressure relief valves and is prepared to demonstrate this activity within the following scope:

Location: � shop � shop and field � field only

Special Processes: � machining � welding � welding (by “R” holder) � heat treatment � NDE*

*If NDE is chosen, specify the method to be used: � RT � UT � MT � PT � ET � NRT � LT � AE

ASME Code Section: � I � III � IV � VIII

Test Media: � Steam � Air � Gas � Liquid

Special NBIC Provisions:

� NB-514, 4.0 Repairs by Manufacturer � Part 3, 4.5.2 Repair by Owner/User � Conversion per Part 3, S7.2 b) � Alternative verification testing per NB-514, 11.0 � Part 3, S7.9 Use of Owner/User Personnel (or Contract Personnel per Interpretation VR-92-01)

and makes application for a National Board of Boiler and Pressure Vessel Inspectors Certificate of Authorization permitting the use of a National Board Pressure Relief Valve Repair stamp for a period to be specified.

In consideration of receipt of said Valve Repair ("VR") stamp, the company agrees that the stamp shall be used only by the named company and in the manner prescribed in the National Board Inspection Code. The company further agrees to surrender the stamp and certificate immediately at any time the National Board may request. Further, the company agrees to surrender said stamp should it discontinue the above mentioned repair activities or no longer have a valid certificate of authorization in its possession. The company further agrees to pay any and all legal fees and National Board costs incurred in the recovery of said stamp and certificate if the above is not complied with and action is necessary. Further, it is agreed that the authorized jurisdiction or the National Board may make audits or unannounced visits as deemed necessary to assure compliance with the rules of The National Board of Boiler and Pressure Vessel Inspectors.

Name of Authorized Representative

Title of Authorized Representative

Telephone Number

Fax Number

Email Address Web Address

X

Signature of Authorized Representative Date

For NB Staff Use:

NB-550, Rev. 20 (3/2014)

Review Report: VR #: ____________ Expiration Date: ____________

Accepted by___________________________ Date _________ Corrective Action Required: Yes No

QC Manual: Corrective Action: _

Accepted by___________________________ Date _________ Accepted by__________________________ Date __________

Valve Repair Verification Testing Completed: Authorization to Issue Certificate:

Date _______________________________________________ Approved by__________________________ Date __________

Company Code: ________

Acct. ID#: _____________

Amount Paid: __________

Type of Payment: _______

Date Received: _________