FORM NS-1 CERTIFICATE HOLDER’S CERTIFICATE OF CONFORMANCE FOR WELDED SUPPORTS* As Required by the Provisions of the ASME Code, Section III, Division 1 Pg. 1 of

1. Manufactured by

2. Manufactured for

3. Location of installation

4. Type

5. ASME Code, Section III, Division 1

6. Identification

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10)

7. Remarks

(name and address of NS Certificate Holder)

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

(name and address of Purchaser)

(name and address)

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

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

(a) Support I.D. No.

(b) Material

Specification No.

(c) Canadian

Registration No.

(d) Applicable

Drawings With Last Rev. & Date

(07/10)

FORM NS-1 (Back — Pg. 2 of )

Support I.D. Nos. through

Design Specification certified by P.E. State

CERTIFICATION OF DESIGN

CERTIFICATE OF CONFORMANCE

P.E. State

Reg. No.

Reg. No. Design Report certified by

(07/10)

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.

Date

NS Certificate of Authorization No. Expires

Name Signed (authorized representative) (NS Certificate Holder)