FORM H-5 MANUFACTURER’S MASTER DATA REPORT FOR BOILERSCONSTRUCTED FROM CAST IRON

As Required by the Provisions of the ASME Code Rules, Section IV

1. Manufactured and certified by

2. Boiler type or model no.

Section Designation(list each individual section

in boiler assembly)

Section Designation Test No. 1 Test No. 2

Bursting Pressure, Metal Thickness Measured at Break orFracture, and eight of Section

Metal ThicknessAccording to Drawing

Pattern and/orPart No.

Test No. 3

Bar forTest No. 3

3. Boiler section data:

4. Boiler section bursting data:

5. Minimum specified tensile strength .

(a)

(a)

Section DesignationBar for

Test No. 1Bar for

Test No. 2

(a)

(b)

(c)

(d)

(e)

(b)

(c)

(d)

(e)

(b)(c)(d)(e)

(name and address of manufacturer) (foundry identification)

7. Specification no. and class of gray iron

8. Maximum Allowable working pressure of boiler*

*Determined by using formula in HC-402 and by selection of lowest values of bursting pressure from tests recorded in item 4 of this report.

6. Tensile strength of associated test bars:

(07/15)

W

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FORM H-5 (Back)

10. Examination data:

12. ASME Certificate of Authorization no. to use the Certification Mark with H designator (cast iron).

NOTE: Signature of designed responsible engineering head of the manufacturer must be notarized.

Certificate expires

(a) Test engineer

9. Sketch of section with lowest bursting pressure:

Show location of

failure and indicate whether

principally in bending or tension.

11. Manufacturer’s certification:

Date

Certified to be true record

,

,

(07/15)

(name)

(b) Witness of test(s)

(c) Date(s) of destruction tests

(name)

(name and title)

Manufactured by

Boiler type or model no.

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