)
Critical Components Data Form
Instructions:
o
If what you want certified (for hazardous location) is a skid or building or contains a series of
certified components: Please fill in below, --(please email back to bstephenson@qps.ca when
completed)
o
If what you want certified is a single device or component itself or an intrinsically safe barrier: you
do not have to fill this form.
o
NOTE:
MUCH, IF NOT ALL, OF THE LIST BELOW WILL BE PART OF THE FINAL REPORT- SO
PLEASE BE DILIGENT
Product Type/Name:
Model Number:
LIST OF CRITICAL COMPONENTS
Component Name
Manufacturer/
Trademark
(what is it?)
Type / Model
No.
Hazardous
location rating
Electrical Rating
Mark(s) of
conformity
PLEASE START
WITH MOTORS
AND
TRANSFORMERS
(if any)
Applicant’s Name:
Signature:
YOUR FULL SERVICE PARTNER IN GLOBAL CONFORMITY ASSESSMENT
81 Kelfield Street, Units 7-9, Toronto, ON M9W 5A3, Ph: 416-241-8857 Fax: 416-241-0682
Web Site: www.qps.ca
Toll Free: 1-877-746-4777
QSD 38Ex
)
Critical Components Data Form
Component Name
(what is it?)
Applicant’s Name:
Manufacturer/
Trademark
Type / Model
No.
Hazardous
location rating
Electrical Rating
Mark(s) of
conformity
Signature:
YOUR FULL SERVICE PARTNER IN GLOBAL CONFORMITY ASSESSMENT
81 Kelfield Street, Units 7-9, Toronto, ON M9W 5A3, Ph: 416-241-8857 Fax: 416-241-0682
Web Site: www.qps.ca
Toll Free: 1-877-746-4777
QSD 38Ex
)
Critical Components Data Form
SAMPLE COMPONENT LIST:
Component
(Customer P/N)
Manufacturer
Mfg P/N
Technical
Description
(hazardous location
markings)
Ratings
(electrical/other)
Mark(s) of
conformity1
Temperature
Transmitter
Rosemount
248HAK6U2NS
Class 1, Div II Gr.
A,B,C,D
12-42 V, 4-20 mA
CSA
Transmitter IS
Wika
12214647
Class 1, Div I Gr.
A,B,C,D
10-30 VDC, 4-20 mA, CSA
0-160 psi
Positioned
ABB
TZIDC x3
Class 1, Div. I Gr.
A,B,C,D
30 VDC max / 4-20
mA
CSA
Electromagnetic
Flow
Endress +
Hauser
Proline Promag
50P x 6
Class 1, Div. II Gr.
A,B,C,D
16-62 V / 4-20 mA
CSA
Explosion Proof
Enclosure
Cooper
Crouse-Hinds
ECP series
Class 1 B,C,D Type na
4
Rapid Exchange
Purge System
Peppler +
Fuchs
Model 2002-STD- Class 1, Div I Gr.
IB Type X
B,C,D
15 ft3 mx enclosure
volume
Solenoid
ASCO
Red Hat
EF8320G202
11.6 Watts, 115 psi
inlet air
Applicant’s Name:
Class 1, Div. 1
A,B,C,D
Signature:
YOUR FULL SERVICE PARTNER IN GLOBAL CONFORMITY ASSESSMENT
81 Kelfield Street, Units 7-9, Toronto, ON M9W 5A3, Ph: 416-241-8857 Fax: 416-241-0682
Web Site: www.qps.ca
Toll Free: 1-877-746-4777
QSD 38Ex
C/UL
CSA, UL