FORM III- I

( See regulation 4)

Certificate of manufacture and test for dished ends / end covers

T.C.NO.: DATE :
Name of the Part :

Maker's Name & Address :

Customer's Name & Address :

Drawing No. : Design Pressure :

(Kg./cm²)
Process of Manufacture, Design Temp.(ºC) :
Material condition, chemical Refer enclosed Raw Heat Treatment :
composition, Tensile material Test Certificates
Strength, Tolerances, : Hydraulic Test :
or Form IV-A in lieu of
Pressure
Bend Test, Flattening Test Raw material Test
etc. Certificates Non-destructive :
Testing

Inspecting Authority Identification Mark:

ITEM MATERIAL QUANTITY MELT No./ TC NO & DATE

PART NAME SIZE SPECN.
No. PLATE NO.

01 PLATE / FORGING

Certified that the particulars entered herein are correct.

Signature and Seal of Maker's Representative Signature and Seal of Maker

Final Inspection Date :

We have satisfied ourselves that the _____________have been constructed in accordance with the Indian Boiler
Regulations, 1950. The test conducted have been witnessed by us and the particulars entered herein are
correct.

Name and Signature of Name and Signature of

Competent Pertson Inspecting Authority

Place :
Date :