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APPENDIX C MANUFACTURER S/INSTALLING CONTRACTOR S REPORT FOR ASME CSD-1 Certification and Reporting CG-500 for Controls and Safety Devices This Form is a guideline and is not part of ASME CDS-1 1998. Unit Manufacturer Name Address Zip Telephone Fax Unit Identification Boiler Manufacturer s Model Year Built ASME Nat* Bd. UL AGA Jurisdiction Steam Hot Water Max W*P. psig Min* Safety Valve Cap* PPH Max. Temp* F Min* Safety Relief Valve Cap* PPH or Btu Boiler Unit Description Type If Modular No* of Modules Boiler Unit Capacity Output Burner Model UL or AGA Serial Fuels as Shipped Installation Location if known Customer Name City State Control/Device Operating Controls Low-Water Fuel Cutoff CW-120 a CW-140 Forced Circulation CW-210 a Steam Pressure CW-310 b Water Temperature Safety Controls High Steam Pressure Limit High Water Temperature Limit Fuel Safety Shutoff Valve Main CF-180 b 2 CF-180 b 3 Pilot Safety Shutoff Valve CF-180 c Atomizing Medium Switch CF-450 b Combustion Air Switch CF-220 High Gas Pressure CF-162 Low Gas Pressure Low Oil Pressure High Oil Temperature Low Oil Temperature Purge Air Flow Flame Safeguard Primary CF-310 CF-320 Low Fire Start CF-610 Safety or Safety Relief Valve s CW-510 CW-520 Operational Test Performed Date Size Capacity PPH/Btu/hr Representing Equipment Manufacturer Name Signature Date Representing Installing Contractor Name /. Unit Manufacturer Name Address Zip Telephone Fax Unit Identification Boiler Manufacturer s Model Year Built ASME Nat* Bd. UL AGA Jurisdiction Steam Hot Water Max W*P. psig Min* Safety Valve Cap* PPH Max. Temp* F Min* Safety Relief Valve Cap* PPH or Btu Boiler Unit Description Type If Modular No* of Modules Boiler Unit Capacity Output Burner Model UL or AGA Serial Fuels as Shipped Installation Location if known Customer Name City State Control/Device Operating Controls Low-Water Fuel Cutoff CW-120 a CW-140 Forced Circulation CW-210 a Steam Pressure CW-310 b Water Temperature Safety Controls High Steam Pressure Limit High Water Temperature Limit Fuel Safety Shutoff Valve Main CF-180 b 2 CF-180 b 3 Pilot Safety Shutoff Valve CF-180 c Atomizing Medium Switch CF-450 b Combustion Air Switch CF-220 High Gas Pressure CF-162 Low Gas Pressure Low Oil Pressure High Oil Temperature Low Oil Temperature Purge Air Flow Flame Safeguard Primary CF-310 CF-320 Low Fire Start CF-610 Safety or Safety Relief Valve s CW-510 CW-520 Operational Test Performed Date Size Capacity PPH/Btu/hr Representing Equipment Manufacturer Name Signature Date Representing Installing Contractor Name /. .

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