Title Page

  • Conducted on

  • Prepared by

  • Site name
  • Equipment serial number


    Defect information
  • A defect - Unsafe, out of service. B defect - To be completed on/before next site visit.
    C defect - Observation/Recommendation

  • Category of defect

  • Description and photos of defect

Additional information

  • Is a site survey required?

  • Have you identified how the remedial can be carried out?

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