TDLR Boiler Extension Request form - BLR221N

Upon TDLR processing of this application, an invoice for the $100.00 Extension fee will be generated. Please only submit extension request one time.

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TX Boiler # (Just the numbers AFTER the TX.)*

Date of last internal inspection:*

Certificate of operation expiration date:*

Type of boiler:*

Organization Information

Organization name:*

Physical address where the boiler is located:*

City:*

State:*

Zip:*

Name of Authorized inspection agency:*

Form submitted by

First Name:*

Last Name:*

Phone Number*

Email Address*

Refer to the Request types below to select the one that best fits your extension request.

Type of extension request:*

In accordance with Texas Boiler Rules, including §65.64 which requires a request for extension to be submitted to TDLR not less than 3 business days prior to the expiration date of the current certificate, we certify:

Standard Request

Continuous water treatment under competent and experienced supervision since last internal inspection.
Accurate and complete records were maintained of boiler water samples taken at intervals not exceeding 24 hours of operation.
Accurate and complete records of dates and reasons object has been out of service, the nature of all repairs, and the reason for those repairs. [TO BE DOCUMENTED BELOW]
For gas fired boilers, the gas pressure regulation or reducing valve servicing the boiler is vented to a safe point of discharge.

Emergency Request

For an EMERGENCY REQUEST for up to an additional 120 days, in accordance with Texas Boiler Rules, including §65.64 which requires an emergency request for extension to be submitted to TDLR prior to the expiration date of the current certificate, we certify all of the above, plus:

It has been established that an emergency exists, an explanation of the emergency is attached.
Our inspection agency’s most current external inspection report is also attached, and it confirms compliance with Texas Health and Safety Code §755.026 as required.

Has this boiler been taken out of service since the last internal inspection other than repairs?*

List the dates that the boiler was out of service other than repairs:

Specify the reason(s) that the boiler was taken out of service for each date:

During this time, was the boiler taken out of service was to conduct repairs? *

Provide the nature of the repairs made to the boiler and the reason(s) that the repairs were made:

Attachments

Please attach any supporting documentation you have relating to your incident, including: receipts, invoices, picture, etc. Color images are encouraged.

Attachments (BMP, DOC, DOCX, GIF, JPEG, JPG, PDF, PNG, TIFF, XLS, XLSX)**

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