Manual Bollard Maintenance Check List

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

FILL OUT FORM COMPLETELY, DO NOT LEAVE ANY QUESTIONS "BLANK" OR "UN-ANSWERED" (TAKE PICTURES IF POSSIBLE)

BOLLARD INFORMATION

• ENTER BOLLARD MANUFACTURER AND MODEL:

  Yes

  No

  N/A

• ENTER BOLLARD ACTUATION TYPE:

  Yes

  No

  N/A

• ENTER BOLLARD SERIAL NUMBER.

  Yes

  No

  N/A

Bollard

• INSPECT BOLLARD APPEARANCE (TOUCH UP PAINT AS REQURED)

  Yes

  No

  N/A

• CLEANED AROUND BOLLARD PLATE?

  Yes

  No

  N/A

• CHECKED REFLECTIVE DECAL ON BOLLARD SLEEVE?

  Yes

  No

  N/A

• CHECKED LATCH AND LATCH MOUNT?

  Yes

  No

  N/A

• CHECKED BOLLARD LATCHES AT UP POSITION?

  Yes

  No

  N/A

• CHECKED BOLLARD LATCHES AT DOWN POSITION?

  Yes

  No

  N/A

PNEUMATIC AND COUNTERWEIGHT

• CHECKED PNEUMATIC/COUNTERWEIGHT SYSTEM BALANCE? (MUST BE ABLE TO PULL UP WITH UNDER 50LBS POWER)

  Yes

  No

  N/A

• CHECKED SYSTEM PRESSURE (RECORD PRESSURE READING) AND CYLINDER?

  Yes

  No

  N/A

• CHECKED COUNTERWEIGHT PULLEY SYSTEM (LUBRICATE AS REQUIRED)?

  Yes

  No

  N/A

BOLLARD PITS

• CHECKED DRAIN (SUSTAINING WATER)?

  Yes

  No

  N/A

• CHECKED SEDIMENT IMPEDING BOLLARD MOVEMENT?

  Yes

  No

  N/A

ADDITIONAL NOTES OR COMMENTS (IF NEEDED)

• ENTER ANY NOTES OR COMMENTS

ELECTRONIC SIGNATURE ACKNOWLEDGE

• ELECTRONIC SIGNATURE ACKNOWLEDGE, I AGREE THAT MY ELECTRONIC SIGNATURE <br>IS A LEGALLY BINDING EQUIVALENT TO MY HANDWRITTEN SIGNATURE. WHENEVER I <br>EXECUTE AN ELECTRONIC SIGNATURE, IT HAS THE SAME VALIDITY AND MEANING AS <br>MY HANDWRITTEN SIGNATURE. I WILL NOT AT ANY TIME IN THE FUTURE, REPUDIATE <br>THE MEANING OF MY ELECTRONIC SIGNATURE OR CLAIM THAT MY ELECTRONIC SIGNATURE <br>IS NOT LEGALLY BINDING.

  Yes

  No

  N/A

• NASATKA REPRESENTATIVE SIGNATURE

  Sign

• CUSTOMER REPRESENTATIVE OR AUTHORIZED REPRESENTATIVE

  Sign