Fillable 150 Des Moines Street Des Moines, IA 50309-1836 (Office of the Chief Information Officer)

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150 Des Moines Street Des Moines, IA 50309-1836 (Office of the Chief Information Officer)

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[
Iowa Division of Labor
Boiler and Pressure Vessel Safety
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5609/515-725-5610
Fax: 515-242-5076
boilers@iwd.iowa.gov
www.iowaboilers.gov
Advance Notice to Convert Power Boiler to Low Pressure Boiler
Date Received:
Object #:
Inspection Date:
222-005
02.04.2020
Owner/User information
Business name
Phone number
Fax number
Address
State
Zip
Object location information
Building name
Phone Number
Address
State
Zip
Object #
Year built
Manufacturer
Old-maximum allowable working
pressure
Old-manufacturers minimum safety valve capacity
and rating
New manufacturers minimum safety valve
capacity and rating
Contractor information (if applicable)
Name
Phone number
Fax number
Email address
Address
State
Zip
I certify that the information on this form is true and accurate to the best of my knowledge. Boiler must meet
ASME CSD-1 requirements. CSD-1 report must be completed and maintained onsite. Please review Iowa
Administrative Code 875-90.15(89) for specific requirements.
Owner/user name
Title
Phone number
Email address
Signature Date
Instructions
The converted boiler must pass inspection prior to operation. Notify the insurance provider if the boiler is covered
by insurance. Iowa Administrative Code Section 875-90.15(89) requires this form be filed with the Labor
Commissioner at least 10 days prior to installation. Prior to installation review the application rules at
www.iowaboilers.gov. Send the completed application to the address above.
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
FOR OFFICE USE ONLY
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150 Des Moines Street Des Moines, IA 50309-1836 (Office of the Chief Information Officer)

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Completed 13 August 2020

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