FORM. VÁLIDO ATÉ 10/2015
QUOTATION NUMBER
APPLICATION REQUEST FORM FOR CERTIFICATION FOR
SPECIAL SITUATION & CRITICAL ANALYSIS RECORD
DEAR CLIENT, THE CORRECT AND COMPLETE FULLFILLMENT OF THIS FORM WILL PERMIT A RIGHT CRITICAL ANALYSIS FOR
A QUICK AND CORRECT ANSWER OF YOUR REQUEST. MISSING INFORMATION CAN STOP US FROM ISSUING A QUOTATION
TO PROVIDE SERVICES.
1 - APPLICANT (MANUFACTURER, AUTHORIZED AGENT, REPRESENTATIVE, LICENSEE OR OTHERS)
NAME/COMPANY NAME
ADDRESS
ZIP CODE
CITY
STATE
TELEPHONE NUMBER
FAX NUMBER
COUNTRY
E-MAIL
2 - IMPORTER (ONLY IF DIFFERENT OF APPLICANT)
COMPANY NAME
ADDRESS
ZIP CODE
CITY
STATE
TELEPHONE NUMBER
FAX NUMBER
COUNTRY
E-MAIL
3 - MANUFACTURER (ONLY IF DIFFERENT OF APPLICANT)
COMPANY NAME
ADDRESS
4 - PRODUCT
GENERIC NAME AND DESCRIPTION (TECHNICAL DATA TO BE INCLUDED IN CERTIFICATE)
MODEL
PRODUCT IDENTIFICATION
SPECIAL CHARACTERISTICS
TRADE NAME
CODE OR MANUFACTURER REFERENCE
5 - PRODUCT DOCUMENTS
DOCUMENT REFERENCE
NUMBER
DATE
ORIGINAL EX CERTIFICATE (S) OF CONFORMITY AND THEIR SUPPLEMENTS, IF ANY
ISO 9001:2008 CERTIFICATION OF THE MANUFACTURER, REGARDING THE PRODUCT
TO BE CERTIFIED
FISCAL IMPORT DOCUMENT FOR THE PRODUCT TO BE CERTIFIED, WITH RESPECTIVE
SERIAL NUMBERS LISTED
APPLICANT DECLARATION FORM FULL FILLED ACCORDING WITH ANNEX A
MARKING DRAWING FOR THE PRODUCTS IN ACCORDANCE WITH ANNEX B
SAFETY WARNINGS DRAWING IN PORTUGUESE
SAFETY INSTRUCTIONS AND INSTALLATION MANUAL IN PORTUGUESE
F-3157-042, REV 3, 05/03/2013
Centro de Pesquisas de Energia Elétrica - CEPEL
www.cepel.br
Sede: Av. Horácio Macedo, 354 - Cidade Universitária - CEP 21941-911 - Rio de Janeiro - RJ - Tel.: 21 2598-6000 - Fax: 21 2260-1340
Unidade Adrianópolis: Av. Olinda, 5800 - Adrianópolis - CEP 26053-121 - Nova Iguaçu - RJ - Tel.: 21 2666-6200 - Fax: 21 2667-3518
Endereço Postal: CEPEL Caixa Postal 68007 - CEP 21944-970 - Rio de Janeiro - RJ - Brasil / Endereço Eletrônico: [email protected]
FORM. VÁLIDO ATÉ 10/2015
6 - CONSIDERATIONS TO PERFORM THE INSPECTION AND ANALYSIS OF DOCUMENTS
REQUIREMENTS TO BE CHECKED DURING THE INSPECTION:
1 – SERIAL NUMBERS;
2 - MARKING OF THE PRODUCT AS ANNEX B;
3 - WARNINGS LABELS IN PORTUGUESE.
NOTE: FOR MODULAR PROCESS UNIT (SKID MOUNTED) ALL CERTIFICATES OF CONFORMITY OF EQUIPMENT /
ELECTRICAL COMPONENTS AND INSTALLATION ACCESSORIES USED IN THE "SKID", SHALL BE LISTED.
DOCUMENTATION TO BE SEND TO CEPEL BY E-MAIL.
ALL THE DOCUMENTATION LISTED AT SECTION 5, IN FILE FORMAT. DOC OR. PDF.
7 - RESPONSIBLE
“I agree in accomplishing the requirements for the Certification, according to the specific Rule of
the Product, and in supplying any necessary information of the products to be certified.”
NAME
POST
SIGNATURE
DATE
WITNESS NAME FOR THE CONTRACT’S SIGNATURE
8 - RESULT OF THE CRITICAL ANALYSIS BASED IN THE GIVEN INFORMATION (FULLFILLMENT BY CEPEL)
PERFORM AUDIT OF THE QUALITY SYSTEM?
YES (
)
NO (
)
JUSTIFY:__________________________________________________________________________________________.
TRANSFERENCE OR ACCEPTANCE OF THE RESULTS IN THE TESTS MADE IN ANOTHER CERTIFICATION? YES (
) NO (
)
JUSTIFY: _________________________________________________________________________________________.
SERVICE POSSBLE TO BE EXECUTED?
YES (
) NO (
) RESPONSIBLE FOR THE ANALYSES: _____________________.
JUSTIFY: ___________________________________________________________________.
DATE ____ / ____ / ____
REMARKS: ________________________________________________________________________________________.
…………………………………………………………………………………………………………………………………………………………………………………/ANNEX A
F-3157-042, REV 3, 05/03/2013
Centro de Pesquisas de Energia Elétrica - CEPEL
www.cepel.br
Sede: Av. Horácio Macedo, 354 - Cidade Universitária - CEP 21941-911 - Rio de Janeiro - RJ - Tel.: 21 2598-6000 - Fax: 21 2260-1340
Unidade Adrianópolis: Av. Olinda, 5800 - Adrianópolis - CEP 26053-121 - Nova Iguaçu - RJ - Tel.: 21 2666-6200 - Fax: 21 2667-3518
Endereço Postal: CEPEL Caixa Postal 68007 - CEP 21944-970 - Rio de Janeiro - RJ - Brasil / Endereço Eletrônico: [email protected]
FORM. VÁLIDO ATÉ 10/2015
ANNEX A
DECLARATION
Regarding our request to CEPEL for the issuance of Certificate of Special Situation for
imported product, in accordance with INMETRO SPECIFIC RULE FOR ELECTRICAL
APPARATUS FOR EXPLOSIVE GAS ATMOSPHERES, published with INMETRO DIRECTIVE
179/2010, we declare on our own responsibility, that:
a)
We, the importer of the product, did not request to any other Brazilian Certification
Body, in the last 6 (six) months, Certification of Special Situation for imported of
limited quantities of Electrical Apparatus for Explosive Gas Atmospheres, using the
certificate of conformity for hazardous locations indicated below;
b)
The product object of our request of Certification of Special Situation for imported
product is not installed at the present time.
Name and address of the company requesting the declaration:
Telephone:
Fax:
E-mail:
Product:
Quantity:
Serial number(s):
Certificate of conformity of the product for use in hazardous locations:
NAME OF THE RESPONSIBLE FOR THIS DECLARATION
POSITION
SIGNATURE OF THE RESPONSIBLE FOR THIS DECLARATION
DATE
In case of skid mounted product, in case the skid do not have its own certificate, it shall be sent one
table containing the information below for all the electrical components of the skid, leaving blank the
field “Certificate of conformity of the product for use in hazardous locations” of the form
“Declaration”.
Item
Name of the product
Model
Quantity
Serial number
Number of the certificate
…………………………………………………………………………………………………………………………………………………………………………………/ANNEX B
F-3157-042, REV 3, 05/03/2013
Centro de Pesquisas de Energia Elétrica - CEPEL
www.cepel.br
Sede: Av. Horácio Macedo, 354 - Cidade Universitária - CEP 21941-911 - Rio de Janeiro - RJ - Tel.: 21 2598-6000 - Fax: 21 2260-1340
Unidade Adrianópolis: Av. Olinda, 5800 - Adrianópolis - CEP 26053-121 - Nova Iguaçu - RJ - Tel.: 21 2666-6200 - Fax: 21 2667-3518
Endereço Postal: CEPEL Caixa Postal 68007 - CEP 21944-970 - Rio de Janeiro - RJ - Brasil / Endereço Eletrônico: [email protected]
FORM. VÁLIDO ATÉ 10/2015
ANNEX B
Marking Drawing for the certification of special situation for imported product
Legenda:
1. Certificate reference with sufix “X” if exist:
Model:
CEPEL AA SE NNNN
, where:
- AA
: year of issue
- SE
:Special Certification reference;
- NNNN : Sequential number.
1
2. Additional information
2
Figure 1 – Marking label
F-3157-042, REV 3, 05/03/2013
Centro de Pesquisas de Energia Elétrica - CEPEL
www.cepel.br
Sede: Av. Horácio Macedo, 354 - Cidade Universitária - CEP 21941-911 - Rio de Janeiro - RJ - Tel.: 21 2598-6000 - Fax: 21 2260-1340
Unidade Adrianópolis: Av. Olinda, 5800 - Adrianópolis - CEP 26053-121 - Nova Iguaçu - RJ - Tel.: 21 2666-6200 - Fax: 21 2667-3518
Endereço Postal: CEPEL Caixa Postal 68007 - CEP 21944-970 - Rio de Janeiro - RJ - Brasil / Endereço Eletrônico: [email protected]