Section
0DFKLQH,QVSHFWLRQVDQG0DLQWHQDQFH
ŽŽŵ>ŝĨƚ
Annual Inspection Report
Date
Serial Number
Model Number
Date of Last Inspection
Date placed in service
Check each item listed below. Use Operator & Service Manuals, and Machine Setting Work Instructions for specific instructions.
Legend:
Y
= Yes / Acceptable
R = Repaired
N = No / Unacceptable
Ø = Not Applicable
Signature Owner/User
ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
Signature Mechanic
ͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺͺ
Inspector Company
Street
City/State/Zip
Phone Number
Contact
Customer
Street
City/State/Zip
Phone Number
Contact
$-(%RRP/LIW2SHUDWRU¶V0DQXDO
3DJH
)81&7,216$1'&21752/6
0DFKLQHKDVWKHODWHVWFRQWUROV\VWHPVRIWZDUH
3HUIRUP6\VWHP7HVWXVLQJ
(.(
KDQGKHOGDQDO\]HU
$OOMR\VWLFNWRJJOHFRQWUROVUHWXUQWRQHXWUDORIISRVLWLRQZKHQUHOHDVHG
'HWHQWVSURSHUO\ORFNFRQWUROVLQQHXWUDORIISRVLWLRQ&KHFNFRQGLWLRQRIFRQWURO
HQFORVXUHVDQGSURWHFWLYHERRWVJXDUGV
)RRWVZLWFKRSHUDWHVSURSHUO\QRWPRGLILHGGLVDEOHGRUEORFNHG
$OOPDFKLQHIXQFWLRQVDUHGLVDEOHGZKHQ(PHUJHQF\6WRS%XWWRQLVDFWLYDWHGDW
JURXQGDQGRUSODWIRUPFRQWUROVWDWLRQV
$OOIXQFWLRQDQGVSHHGOLPLWVFXWRXWVRSHUDWHSURSHUO\
0DQXDOGHVFHQWV\VWHPDQGRUDX[LOLDU\SRZHUV\VWHPRSHUDWHVSURSHUO\
7RZHUERRPV\FKURQL]DWLRQDQGVHTXHQFHV\VWHPRSHUDWHVSURSHUO\
/RDG6HQVLQJ6\VWHPRSHUDWHVSURSHUO\
6N\*XDUGRSHUDWHVSURSHUO\
&DSDFLW\LQGLFDWRUV\VWHPRSHUDWHVSURSHUO\
6ZLQJDQG'ULYH%UDNHVRSHUDWHSURSHUO\
$OORWKHUPDFKLQHFRQWUROVDODUPVKRUQGLVSOD\VLQGLFDWRUVDQGIXQFWLRQV
RSHUDWHSURSHUO\DWSODWIRUPDQGJURXQGFRQWUROVWDWLRQV
3/$7)250$66(0%/<
3ODWIRUPSURSHUO\LQVWDOOHGDQGVHFXUH0RXQWLQJKDUGZDUHIUHHRIGDPDJHDQG
VHFXUH*DWHRSHQVDQGODWFKHVSURSHUO\
3ODWIRUPJXDUGUDLOVDQGIORRULQSODFHVHFXUHDQGIUHHRIGDPDJH
6N\*XDUGSURSHUO\PRXQWHGDQGIUHHRIGDPDJH
/DQ\DUGDQFKRUDJHSRLQWVVHFXUHIUHHRIGDPDJHDQGODEHOHG
%220$66(0%/<
%RRPVHFWLRQVDQGUHODWHGZHOGPHQWVIUHHRIGDPDJHGLVWRUWLRQDQGH[FHVVLYH
ZHDU
,QVSHFWDOOQXWVEROWVSLQVVKDIWVVKLHOGVEHDULQJVZHDUSDGVORFNLQJ
GHYLFHVVKHDYHVVKHDYHSLQVDQGEHDULQJVIRUSURSHULQVWDOODWLRQVHFXUHQR
H[FHVVLYHZHDUFUDFNVRUGLVWRUWLRQ
,QVSHFWSODWIRUPURWDWRUVDQGMLEURWDWRUVIRUSURSHULQVWDOODWLRQIUHHRIGDPDJH
SURSHURSHUDWLRQDQGIUHHRIOHDNV
%220$66(0%/<
FRQWLQXHG
%RRPFKDLQVDQGFDEOHVDUHIUHHRIGDPDJHSURSHUO\LQVWDOOHGSURSHUO\WRUTXHG
DQGSURSHUO\OXEULFDWHG
3RZHUWUDFNLVIUHHRIGDPDJHGLVWRUWLRQDQGH[FHVVLYHZHDU&DEOHVKRVHVDUH
SURSHUO\URXWHGQRFKDILQJRUOHDNV
,QVSHFWDOOF\OLQGHUSLQVSLYRWSLQVDWWDFKLQJDQGUHWHQWLRQKDUGZDUHIRUGDP
-
DJHGLVWRUWLRQDQGH[FHVVLYHZHDU
78517$%/(
'RRUVFRYHUVIDVWHQSURSHUO\DQGDUHVHFXUH&DQEHRSHQHGDVLQWHQGHG
7XUQWDEOHEHDULQJVZLQJGULYHDQGJHDUVHFXUHIUHHRIGDPDJHDQGSURSHUO\
OXEULFDWHG1RPLVVLQJEHDULQJEROWVRUVLJQVRIORRVHQHVV
3HUIRUPWXUQWDEOHEHDULQJPRXQWLQJEROWFRQGLWLRQFKHFNDQGZHDUWROHUDQFH
FKHFN
7XUQWDEOHORFNVHFXUHIUHHRIGDPDJHDQGRSHUDWHVSURSHUO\
&+$66,6
:KHHODWWDFKPHQWKDUGZDUHWRUTXHGSURSHUO\1RPLVVLQJDWWDFKPHQWKDUGZDUH
7UDFNDQG5ROOHUDVVHPEO\SURSHUO\VHFXUHG1RPLVVLQJDWWDFKPHQWKDUGZDUH
,QVSHFWIRUZRUQWUDFNFXWVWHDUVRURWKHUGLVFUHSDQFLHV,QVSHFWUROOHUVIRUGDP
-
DJHDQGFRUURVLRQ
3URSHUZKHHOVWLUHVLQVWDOOHG,QVSHFWIRUH[FHVVLYHGDPDJHZHDUDQGFRUURVLRQ
,ISQHXPDWLFSURSHUO\LQIODWHGDQGPRXQWHG
6WHHULQJFRPSRQHQWVDUHSURSHUO\LQVWDOOHGVHFXUHDQGIUHHRIGDPDJH
&KHFNGULYHKXEVIRUSURSHUIOXLGOHYHO
7RQJXHMDFNDQGVDIHW\EUHDNDZD\FKDLQVSURSHUO\LQVWDOOHGDQGRSHUDWLRQDOIUHH
RIGDPDJHDQGVHFXUH
2VFLOODWLQJD[OHRSHUDWHVSURSHUO\
2XWULJJHUH[WHQGLEOHD[OHVRSHUDWHSURSHUO\,QWHUORFNVIXQFWLRQSURSHUO\
32:(56<67(0
"MM#BUUFSZDBCMFTUJHIU
3URSHUEDWWHU\IOXLGOHYHO%DWWHU\FKDUJHURSHUDWHVSURSHUO\%DWWHULHVDFFHSW
FKDUJH
#BUUFSJFTBOEDBCMFTGSFFPGDPSSPTJPO
"MM&MFDUSJD%SJWFDBCMFTUJHIUBOEGSFFPGEBNBHF
$IFDLFMFDUSJDBMDPOOFDUJPOT
#BUUFSZBOE.BTUFS%JTDPOOFDUPQFSBUFQSPQFSMZ
+<'5$8/,&(/(&75,&$/6<67(0
$OOF\OLQGHUVIUHHRIGDPDJHZLWKQRHYLGHQFHRIOHDNV
$OODUHDVDURXQGK\GUDXOLFFRPSRQHQWVKDYHQRHYLGHQFHRIOHDNV
+\GUDXOLFRLOV\VWHPSURSHUO\VHUYLFHGDQGIUHHRIFRQWDPLQDQWV
$OOK\GUDXOLFKRVHVILWWLQJVDQGOLQHVVHFXUHDQGIUHHRIGDPDJH&KHFNIRUFKDI
-
LQJDQGOHDNV
$OOHOHFWULFDOFRQQHFWLRQVWLJKWQRFRUURVLRQRUDEUDVLRQV
3XPSDQGPRWRUVHFXUHIUHHRIGDPDJHDQGOHDNV
$OOK\GUDXOLFSUHVVXUHVSURSHUO\DGMXVWHG
0$18$/6$1''(&$/6
2SHUDWLRQDQG6DIHW\0DQXDO$16,6$,$0DQXDORI5HVSRQVLELOLWLHV$16,PDU
-
NHWVRQO\DQG$(0+DQGERRN$16,PDUNHWVRQO\LQPDQXDOVWRUDJHER[
$OOVDIHW\FDSDFLW\DQGLQVWUXFWLRQDOGHFDOVLQVWDOOHGVHFXUHDQGOHJLEOH
*(1(5$/
0DFKLQHLVIUHHRIXQDXWKRUL]HGPRGLILFDWLRQVRUDGGLWLRQV
$SSOLFDEOH6DIHW\%XOOHWLQVFRPSOHWHG
,QVSHFWJHQHUDOVWUXFWXUDOFRQGLWLRQLQFOXGLQJDOOZHOGV
*UHDVHDQGOXEULFDWHSHU6HUYLFHDQG0DLQWHQDQFH0DQXDO
'ULYHDQGRSHUDWHPDFKLQHWRWHVWDOOPDFKLQHIXQFWLRQV
5HFRUGLQVSHFWLRQGDWHDW
$IBTTJT
GHFDO
1RWLI\
(.(
RIDQ\RZQHUVKLSFKDQJHV
