Complete the yellow highlighted areas and submit signed letter on company letterhead

NAME OF THE SUBMITTER

COMPANY NAME

COMPANY ADDRESS

COMPANY CONTACT INFORMATION

SUBMITTER’S EMAIL

DATE

Sarah Patterson

Chairman, Hydrostatic Stress Board

105 Decker Court, Suite 825

Irving, Texas 75062

RE: PPI TR-4 - Listing Request (for a composite pipe)

Dear HSB Chairman,

COMPANY NAME is requestingto list the following product(s) in the Plastics Pipe Institute’s Hydrostatic Stress Board (PPI HSB) program at a STANDARD GRADE or EXPERIMENTAL GRADElisting level.

PRODUCT NAME1

  • MATERIAL DESIGNATION
  • Requested Experimental Grade level (e.g., E4, E6, E8, etc.)
  • Recommended HDB1/MRS1/PDB1- at X-temperature1
  • Recommended HDB2/MRS2/PDB2- at X-temperature2
  • Recommended HDB3/MRS3/PDB3- at X-temperature3

Note1, if a PDB listing, detail the following information:

  • Construction (e.g., number of layers; thickness of the layers; does construction include a barrier layer or include a metallic layer such as aluminum; is a component dispersed in the polymer matrix, such as fiberglass fibers in a polyolefin, etc.)
  • Materials of used in the construction (e.g., PE 4710, PE 100, PE 2708, EVOH, aluminum, fiberglass, name of the polymeric compound, etc.)

PRODUCT NAME2

  • MATERIAL DESIGNATION
  • Requested Experimental Grade level (e.g., E4, E6, E8, etc.)
  • Recommended HDB1/MRS1/PDB1- at X-temperature1
  • Recommended HDB2/MRS2/PDB2- at X-temperature2
  • Recommended HDB3/MRS3/PDB3- at X-temperature3

Note, if a PDB listing, detail the following information:

  • Construction (e.g., number of layers; thickness of the layers; does construction include a barrier layer or include a metallic layer such as aluminum; is a component dispersed in the polymer matrix, such as fiberglass fibers in a polyolefin, etc.)
  • Materials of used in the construction (e.g., PE 4710, PE 100, PE 2708, EVOH, aluminum, fiberglass, name of the polymeric compound etc.)

This request includes the regression data, material designation for any compound used in the constructionand construction details as required by PPI TR-3 (see accompany reports). We understand and agree that this listing is given subject to the policies and procedures set forth in PPI TR-2 and PPI TR-3.

COMPANY NAMEagrees to hold the Plastics Pipe Institute (PPI) harmless and indemnify PPI for any and all liability, loss, damage, cost and expense which PPI may suffer, incur, or be put to by reason of any claim, suit or proceeding for personal injury, property damage or economic loss on account of the failure or alleged failure of the compound listed (or pipe produced from the compound) to conform to specifications on which the listing is based, or based on the HDB, MRS, PDB or SDB assigned to the compound, and COMPANY NAMEfurther agrees to defend PPI at COMPANY NAME’s expense against any and all such claims, suits or proceedings.

Best Regards,

AUTHORIZED SIGNATURE

TITLE

©Copyright2018, The Plastics Pipe Institute, Inc. 1