BOILER AND PRESSURE VESSEL

OWNER:

STATE:

CITY:

ZIP

USER:

REPORT

DATE BILLED (OFFICE USE):

INSPECTION AGENCY:

ADDRESS:

PERSON CONTACTED:
STATE:

CITY:

STATE NO.

INSPECTION

LABOR & INDUSTRIES

BOILER SECTION

ADDRESS:

NATL. BOARD
SERIAL NUMBER

TYPE VESSEL

ZIP

MANUFACTURER

REMARKS:

F620-005-000 boiler and pressure vehicle inspection report 12-01

PHONE:

INSPECTOR SIGNATURE:
MAX.
ALLOW.
SIZE SQ/FT
YEAR BUILT WORK.
/GAL
PRESS. ON
CERT.

ID #:

LOCATION

DATE
INSPECTED

CERTIFICATE
EXPIRES

INT
EXT

ISSUE
CERT

INSP FEE CERTIFCATE FEE