FORM NF-1 CERTIFICATE HOLDER’S DATA REPORT FOR SUPPORTS* As Required by the Provisions of the ASME Code, Section III, Division 1

(07/10)

Pg. 1 of

1. Manufactured by

2. Manufactured for

3. Location of installation

4. Type

(a) Support I.D. No.

(1)

(2)

(3)

(4)

(b) Material

Specification No.

(c) Canadian

Registration No.

(d) Applicable

Drawings With Last Rev. & Date

(e) National

Board No.

5. ASME Code, Section III, Division 1

6. Identification

(5)

(6)

(7)

7. Remarks

(8)

(9)

(10)

*Supplemental information in the form of lists, sketches, or drawings may be used provided: (1) size is 81/2 � 11; (2) information in items 1 through 4 on this Data

Report is included on each sheet; and (3) each sheet is numbered and the number of sheets is recorded at the top of this form.

(name and address of NPT Certificate Holder)

(Design Report or Load Capacity Data Sheet) (Year built) (describe)

(edition) [Addenda (if applicable) (date)] (class) (Code Case no.)

(name and address of Purchaser)

(name and address)

FORM NF-1 (Back — Pg. 2 of )

CERTIFICATION OF DESIGN

and state that to the best of my knowledge and belief, the Certificate Holder has constructed these supports in accordance with the ASME Code, Section III, Division 1.

By signing this certificate, neither the inspector nor his employer makes any warranty, expressed or implied, concerning the component supports described in this Data Report. Furthermore, neither the inspector nor his employer shall be liable in any manner for any personal injury or property damage or a loss of any kind arising from or connected with this inspection.

Design Report certified by

Design Specification certified by

P.E. State

Support I.D. Nos. through

Reg. No.

P.E. State Reg. No.

Date Signed Commission (Authorized Nuclear Inspector) [National Board Number and Endorsement]

I, the undersigned, holding a valid commission issued by the National Board of Boiler and Pressure Vessel Inspectors and employed by

of

have inspected the supports described in this Data Report on , ,

We certify that the statements made in this report are correct and that these supports conform to the rules for construction of the ASME Code, Section III, Division 1.

CERTIFICATION OF COMPLIANCE

CERTIFICATE OF INSPECTION

NPT Certificate of Authorization No. Expires

Date Name Signed (NPT Certificate Holder) (authorized representative)

(07/11)