Quality Surveillance Release Certificate

TR-80-FRM-00-106-01

PO Item Quantity Description Tag Item # as per PO

001 1 Inspection Horizontal Pressure Vessel. #001

Note: The Action Items List pertaining to this Purchase Order must be attached to this
document.
Partial Inspection Release Full Inspection Release QSR Initials here → BM
Without exceptions QSR Initials here → MH
QSR Initials here → RZ
With the following authorized exceptions / deficiencies: QSR Initials here → JR
• Pressure vessel didn’t pass last inspection. Uncompleted.

QUALITY SURVEILLANCE REPRESENTATIVE (QSR) ACKNOWLEDGES:

Signing this release is solely for the purpose of authorizing the supplier to initiate the shipment of
goods on this order with the engineering contractor. Such authorization shall not relieve the supplier of
its obligations set out in the purchase order, including without limitation the warranty that the goods
are free from defects. I hereby confirm that all required inspections as detailed within the Inspection
Assignment and Purchase Order have been performed with satisfactory results.

Name of QSR or End-User

Representative
Brian Marin Date Aug 134, 2021

Signature & Title Brian Marin – 6ty 9ers Welding Inc. Representative
SUPPLIER'S CONFORMANCE STATEMENT:
We certify that the PO items listed, and the required QC / Shipping documentation meet or will meet
the requirements at our costs all applicable Code, Standards, specification and other related documents
as set forth in the purchase order document. The accepted preliminary QC documentation, bill of lading,
packing slip, and all related shipping documents must accompany the shipped goods and be added as a
line item on the packing list.
Agreed by

Supplier Rep Name: Date

Signature & Title

December 2013 Page 1 of 1 TR-80-FRM-00-106-01 Rev 3