Manufacture Representative

Authorized Inspector

FORM UV-1 MANUFACTURER’S OR ASSEMBLER’S CERTIFICATE OF CONFORMANCE FOR PRESSURE RELIEF VALVES
As Required by the Provisions of the ASME Boiler and Pressure Vessel Code Rules, Section VIII, Division 1

1. Manufactured (or assembled) by

2. Table of Certification Mark stamped items:

Year NB Set
I.D. # Built Cert. # Qty. Type Size Pressure Capacity Test Fluid Date CI Name CI Signature

3. Remarks

CERTIFICATE OF SHOP COMPLIANCE

By the signature of the Certified Individual (CI) noted above, we certify that the statements made in this report are correct and that all
details for design, material, construction, and workmanship of the pressure relief devices conform with the requirements of Section VIII,
Division 1 of the ASME BOILER AND PRESSURE VESSEL CODE.

UV Certificate of Authorization No. Expires

Date Signed Name

(responsible representative) (Manufacturer or Assembler)

(07/13)