INSP Reg. Nr.

9071
Skippergade 1, Box 230 - DK-6700 Esbjerg, Denmark - Phone (+45) 75 13 00 50 - Fax (+45) 75 13 00 57

INSPECTION CERTIFICATE
Client:
Certificate NO: 0000X
Issued date: xxxx-xx-xx
Page 1 of 1
Owner: Enclosure: Yes. No.
Applus Ref.: A - 000x
Place of Inspection:
Product Identification:

Scope of Inspection:
According to Standard:

Type of Inspection/ Test: Visual Inspection Pressure Test Leakage Test Lifting Test
Non-Destructive Test Other:
The Inspection is performed according to approved QIB Procedure No.:

Supporting Test Report(s)

Pressure Test Report No.: N/A
Leakage Test Report No.: N/A
Lifting Test Report No.: N/A
Non-Destructive Test Report No.: N/A
Other Test Reference No.: N/A
When applicable for the Uncertainty of Measurements reference is made to the supporting documentation.
Inspections and results marked <…*…> in this report are not covered by the company’s accreditation.

The Product specified above has been Inspected according to the stated requirements and found to be:
Acceptable to Quality requirements Date of Inspection:
Not-acceptable to Quality requirements
The Product plate is marked:

Inspectors Name: Signature: Mark or Seal:

Remarks:

Declaration of Conformity
We hereby declare that the above specified Product, at the time of Inspection, was thoroughly examined
according to the stated standard. The Inspection results are only valid for the Product with the above stated
Product Identification.
A+010-3/0

Managing Director: 10 November 2010

© This Inspection Certificate shall not be reproduced except in full without the written approval of Applus RTD and the Client.