Newcomb and Company Forklift Daily Checklist

• Forklift Operator Evaluation Form

• Conducted on

  Date

• Evaluator Name

• Mitsubishi Fork Lift <br>Model FG25N-LP

  Off

  On

Industrial trucks shall be examined at least daily before being placed in service for that day.

• Is the owner's manual present?

  Yes

  No

  N/A

• Hour Meter Reading

• Tires

  Good

  Fair

  Poor

  N/A

• Horn<br>

  Good

  Fair

  Poor

  N/A

• Lights

  Safe

  At Risk

  N/A

• Battery

  Good

  Fair

  Poor

  N/A

• Controller

  Good

  Fair

  Poor

  N/A

• Lift system to include load limit switches, load engagement means, chains, cables, forks, etc.

  Yes

  No

  N/A

• Brakes

  Safe

  At Risk

  N/A

• Steering Mechanism, Free play in steering

  Safe

  At Risk

  N/A

• Leaks in hydraulic system. Check hydraulic fuel level

  Safe

  At Risk

  N/A

• Leaks in fuel system, smell for leaks in propane system

  Safe

  At Risk

  N/A

• Is truck clean, free of excessive dirt, oil and grease?

  Good

  Fair

  Poor

  N/A

• Overhead guards broken or damaged

  Safe

  At Risk

  N/A

• Gauges working properly

  Yes

  No

  N/A

• Seat belts work properly

  Good

  Fair

  Poor

  N/A

• Is propane tank locked down and secure?

  Yes

  No

  N/A

• Forks and locking pins

  Safe

  At Risk

  N/A

• Engine oil ok?

  Safe

  At Risk

  N/A

• Transmission fluid ok?

  Safe

  At Risk

  N/A

• Windshield wipers in good condition, if equipped

  Good

  Fair

  Poor

  N/A

• All name plates and markings are in place and maintained in legible condition

  Good

  Fair

  Poor

  N/A

• List any others problems found with the truck.

• Inspector's Signature

  Sign