APPLICATION FOR CERTIFICATE OF AUTHORIZATION TO …

1 TEXAS DEPARTMENT OF LICENSING AND REGULATION Regulatory Program Management Division/Boiler Program P. O. Box 12157 Austin, Texas 78711 (512) 539-5716 Fax (512) 539-5687 Email Address: Web site: tdlr FORM 001 BLR 5/18 1 APPLICATION FOR CERTIFICATE OF AUTHORIZATION TO REPAIR AND/OR ALTER BOILERS Upon tdlr receipt of this APPLICATION , an invoice for the $1, Special Inspection fee will be generated. This fee must be paid before this review will be scheduled. Chief Boiler Inspector Texas Department of Licensing and Regulation Box 12157 Austin, Texas 78711 The owner/operator named below hereby attests that it can repair alter repair and alter boilers covered by the Texas Boiler Law and is prepared to demonstrate this activity within the following scope: Location: Shop Field Shop and FieldASME Code Section I IV VIII, Div. 1and makes APPLICATION for: initial issuance renewal of the owner/operator CERTIFICATE of AUTHORIZATION .

2 In consideration of receipt of the owner/operator CERTIFICATE of AUTHORIZATION we hereby agree that the CERTIFICATE shall be used exclusively for boilers encompassed by the Texas Boiler Law at the location(s) listed below. Further, it is agreed that the Chief Inspector or his designated representative may make audits or unannounced visits as necessary to assure compliance with the requirements of the Texas Boiler Law and associated rules. Owner/Operator Name Company or corporate name, department, division, etc. Physical Location Mailing Address Address Address City, State, ZIP Code City, State, ZIP Code Authorized Inspection Agency (AIA): AUTHORIZED REPRESENTATIVE Telephone number FAX Email Type Name Signature Title Date LIST ON THE BACK OF THIS FORM ADDITIONAL LOCATIONS FOR CERTIFICATE OF AUTHORIZATION TO BE ISSUED tdlr FORM 001 BLR 5/18 2 ADDITIONAL LOCATIONS FOR CERTIFICATE OF AUTHORIZATION TO BE ISSUED (1) (10) Street address or closest intersection Street address or closest intersection City, State, ZIP Code City, State, ZIP Code (2) (11) Street address or closest intersection Street address or closest intersection City, State, ZIP Code City, State, ZIP Code (3) (12) Street address or closest intersection Street address or closest intersection City, State, ZIP Code City, State, ZIP Code (4) (13) Street address or closest intersection Street address or closest intersection City, State, ZIP Code City, State, ZIP Code (5) (14) Street address or closest intersection Street address or closest intersection City, State, ZIP Code City, State, ZIP Code (6) (15)

3 Street address or closest intersection Street address or closest intersection City, State, ZIP Code City, State, ZIP Code (7) (16) Street address or closest intersection Street address or closest intersection City, State, ZIP Code City, State, ZIP Code (8) (17) Street address or closest intersection Street address or closest intersection City, State, ZIP Code City, State, ZIP Code (9) (18) Street address or closest intersection Street address or closest intersection City, State, ZIP Code City, State, ZIP Code Submit completed form to tdlr Boiler Program: 1) via email to 2) via fax to 512-539-5687; or 3) via USPS to tdlr , ATTN: Boiler Program, PO Box 12157, Austin, TX 78711.