CERTIFICATE OF AUTHORISATION APPLICATION FORM - …

1 Page 1 of 2 APPLICATION for Non-Nuclear Ontario CERTIFICATE of authorization Technical Standards and Safety Act Boilers and Pressure Vessels Regulation This APPLICATION is for the following location: Company (Applicant) Name: (Full company name as it should appear on CERTIFICATE of authorization ) Corp No. or Business Identification No: Phone Number: Email: Billing/Mailing Address Street No.: Street Name: Unit/Suite: City Town: Province: Postal Code: Department/Division: (if required on CERTIFICATE ) Facility Address: (Full street address - DO NOT PROVIDE A BOX) This APPLICATION is for (check all applicable): RENEWAL CERTIFICATE NEW CERTIFICATE FIELD SITE FACILITY/NAME CHANGE ASME Only PLANT C SA B51 Only ASME & CSA B51 If Renewal: (Current CERTIFICATE Number(s)) Expiration Date(s): Type of CERTIFICATE of authorization for which APPLICATION is being made, check all applicable boxes.

2 Power Boilers Manufacturer Heating Boilers Manufacturer Pressure Vessels Manufacturer Boiler Proper Piping Power Piping Systems as per Include Boiler External Piping Process Piping Systems as per Refrigeration piping Medical Gas Piping Repairs or Alterations of Boilers, Pressure Vessels, Piping, Fitting Pressure Relief Valve Repair Fitting Manufacture A B C D E F H Hot Tap & Line Stopping Welded Mechanical On Line Leak Sealing Owner/User Repair with Self Inspection Management Program for Safety Relief Valve Service Interval Installation and Operation of Pressure Vessels per ASME BPVC Section VIII Appendix M Third Party Authorized Inspection Agency Technical Standards & Safety Authority Page 2 of 2 Is your company a Trade Association member YES NO Are you using (MCA, ORAC or HRAI) Corporate Quality Manual YES NO Name of Authorized Inspection Agency (Outside Ontario only): Do you have a signed TSSA inspection services agreement?

3 YES NO Deposit: Ontario applicants please include a cheque for the survey fee deposit with this APPLICATION as follows: # Description Deposit Required Amount submitted 1 All Non-Nuclear Certificates $3,110* 2 Trade Organization $2,200* 3 Third Party Authorized Inspection Agency Program $4,140* 4 Installation and Operation of Pressure Vessels per ASME BPVC Section VIII , Appendix M & Management Program for Safety Relief Valve Service Interval Current Hourly Rate as per Fee Schedule* NOTES: 1)Ontario applicants, please include a cheque for the survey deposit fee with this APPLICATION as shown )Total survey charges will include the above noted deposit amount, plus hourly billing at the current inspection rate asoutlined in the Boiler and Pressure Vessels Fee Schedule for the Authorized Inspector and Authorized InspectorSupervisor s travel, expenses and Survey time.

4 (Applies to: ASME / CSA B51 / Section VIII-Div. 1 Audits)3)Applicants outside of Ontario do not send payments. After receipt of the APPLICATION , a quote will be provided andprepayment in the full amount of the quote will be required prior to the audit being )Any Extra time for T eam Leader and Inspector (if required) due to additional location and follow-ups will be billed percurrent inspection rate as outlined in the Boilers and Pressure Vessels Fee )The following activities related to the Survey such as: Quality Manual pre-reviews, meetings and/or consultations, pre-survey inspections (and/or site visits), and post-survey follow-ups (site visits and/or document review) will be billed at thecurrent inspection rate as outlined in the Boilers and Pressure Vessels Fee )Each CERTIFICATE of authorization will be invoiced at a cost of $ per CERTIFICATE , upon completion of a ) *13% HST is applicable to the Survey fee, hourly inspections billing, and cancellation/postponement fees.

5 8)Inspection fees may also apply to TSSA Ontario surveys and are invoiced separately in addition to the Survey FeeDeposit. Cancellation Fees: Cancellation or postponement, by an applicant, of a previously scheduled survey in Ontario, which occurs 15 working days or less from the agreed site implementation survey date, is invoiced as follows; - Non-Nuclear surveys $1,020 Cancellation or postponement, by an applicant, outside Ontario, which occurs 30 working days or less from the agreed site implementation survey date will be invoice per above Cancellation or Postponement Fee and any additional charges due to air fare changes. By signature below and as a part of TSSA accreditation the applicant accepts all conditions related to the issue and use of the CERTIFICATE of authorization provided by TSSA and agrees to unannounced TSSA audits of the program at TSSA s discretion.

6 Send this APPLICATION form with the cheque to: Technical Standards and Safety Authority Boilers and Pressure Vessels Safety Division 345 Carlingview Drive Toronto, ON M9W 6N9 APPLICANT authorization Name (print) Signature Date PV 09555 (April 2018)