Fillable Manufacturers/Installing Contractors Report for ASME CSD-1-2012 (Office of the Chief Information Officer)

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Manufacturers/Installing Contractors Report for ASME CSD-1-2012 (Office of the Chief Information Officer)

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BROWSE OFFICE OF THE CHIEF INFORMATION OFFICER (IA) FORMS

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Unit Identification (Boiler)
Manufacturer’s
Model #
Year
Built
ASME
Section (1)
Section (IV)
National
Board #
UL #
CSA #
Jurisdiction
Unit
Description (type)
Unit
Capacity (output)
Steam Hot Water
Maximum
W.P. psig
Maximum
W.P. psig
Minimum Safety
Valve Capacity PPH
Maximum
Temperature °F
Minimum Safety
Relief Valve Capacity
PPH BTU
Burner – Indicate Units (where not applicable, indicate “N/A”)
Manufacturer
Model
UL or CSA #
Serial #
Fuels
(as shipped)
Gas Manifold
Pressure
Oil Nozzle/
Delivery Pressure (at max pressure)
High Gas Pressure
Switch Setting
Low Oil Pressure
Switch Setting
Unit Manufacturer
Name
Address
City
State
Zip
Phone
Number
Fax
Number
Installation Location
Customer
Name
Address
City
State
Zip
Phone
Number
Fax
Number
This form is a guideline and NOT part of ASME CSD-1-2012
222-02 02.15.2016 Page 1
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
NONMANDATORY APPENDIX C
Manufacturer’s/Installing Contractor’s
Report for ASME CSD-1-2012
Certification and Reporting (CG-500) for Controls and Safety Devices
Certification and Reporting (CG-500) for Controls and Safety Devices
.
Control/Device
Manufacturer
Model
Number
Date Operational
Test Performed
Operating Controls
Low-Water Fuel Cutoff
CW-120(a), CW-140
Forced Circulation - CW-210(a)
Steam Pressure - CW-310(b)
Water Temperature – CW-410(b)
Safety Controls
Low-Water Fuel Cutoff
CW-120(a), CW-120(b), CW-130, CW-140
Forced Circulation - CW-210(b)
High Steam Pressure Limit - CW-310(c)
High Water Temperature Limit
CW-410(b)
Fuel Safety Shutoff Valve, Main
CF-180(b)(2), CF-180(b)(3)
Pilot Safety Shutoff Valve - CF-180(c)
Atomizing Medium Switch - CF-450(b)
Combustion Air Switch - CF-220
High Gas Pressure - CF-162
Low Gas Pressure - CF-162
Low Oil Pressure - CF-450(a)
High Oil Temperature - CF-450(c)
Low Oil Temperature - CF-450(d)
Purge Air Flow - CF-210
Flame Safeguard (Primary)
CF-310, CF-320
Flame Detector – CF-310, CF-320
Low Fire Start
Low-Fire Start Switch - CF-610
Safety or Safety Relief Valve(s)
CW-510, CW-520
Manufacturer
Model
Size
Capacity
PPH BTU hr
Date of Operational
Test Performed
Representing Equipment Manufacturer
Name Signature Date
Repr
esenting Installing Contractor
Name Signature Date
This form is a guideline and NOT part of ASME CSD-1-2012
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ManufacturersInstalling Contractors Report for ASME CSD-1-2012 (Office of the Chief Information Officer)

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Completed 13 August 2020

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