PSE Annual Vehicle Inspection Form (DOT)

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Date and Time audit began

  Date

• Motor Carrier Operator Name And Address

  Yes

  No

  N/A

• Inspector's Name

  Yes

  No

  N/A

• The inspector meets the qualification requirements in section 396.19.

  Yes

  No

  N/A

• Vehicle Type

  Tractor

  Trailer

  Truck

  Bus

  Other

• Vehicle Identification

  License plate

  VIN

  Other

• Fleet Unit Number

  Yes

  No

  N/A

• Odometer reading at Inspection

• Photograph of Vehicle Being Inspected

  Media

Vehicle Components Inspected

1. Brake System

• a. Service Brakes

  Safe

  At Risk

  N/A

• b. Parking Brake System

  Safe

  At Risk

  N/A

• c. Brake Drums or Rotors

  Safe

  At Risk

  N/A

• d. Brake Hose

  Safe

  At Risk

  N/A

• e. Brake Tubing

  Safe

  At Risk

  N/A

• f. Low Pressure Warning Device

  Safe

  At Risk

  N/A

• g. Tractor Protection Valve

  Safe

  At Risk

  N/A

• h. Air Compressor

  Safe

  At Risk

  N/A

• I. electric Brakes

  Safe

  At Risk

  N/A

• j. Hydraulic Brakes

  Safe

  At Risk

  N/A

• k. Vacuum System

  Safe

  At Risk

  N/A

2. Coupling Devices

• a. Fifth Wheels

  Safe

  At Risk

  N/A

• b. Pintle Hooks

  Safe

  At Risk

  N/A

• c. Drawbar/Tow bar Eye

  Safe

  At Risk

  N/A

• d. Drawbar/Tow bar Tongue

  Safe

  At Risk

  N/A

• e. Safety Devices

  Safe

  At Risk

  N/A

• f. Saddle- mounts

  Safe

  At Risk

  N/A

3. Exhaust System

• a. Exhaust system leaking forward of or directly below the driver/sleeper compartment

  Safe

  At Risk

  N/A

• b. Bus exhaust system leaking or discharging in violation of standard

  Safe

  At Risk

  N/A

• c. Exhaust system likely to burn, char, or damage the electrical wiring, fuel supply, or any combustible part of the motor vehicle

  Safe

  At Risk

  N/A

4. Fuel System

• a. Visible leak

  Yes

  No

  N/A

• b. Fuel tank filler cap missing

  Yes

  No

  N/A

• c. Fuel tank securely attached

  Yes

  No

  N/A

5. Lighting Devices

• All lighting devices and reflectors required by part 393 shall be operational

  Yes

  No

  N/A

6. Safe Loading

• a. Parts of vehicle or condition of loading such that the spare tire or any part of the load or dunnage can fall onto the roadway

  Safe

  At Risk

  N/A

• b. Protection against shifting cargo

  Safe

  At Risk

  N/A

• c. Container securement devices on intermodal equipment

  Safe

  At Risk

  N/A

7. Steering Mechanism

• a. Steering wheel free play

  Safe

  At Risk

  N/A

• b. Steering Column

  Safe

  At Risk

  N/A

• c. Front axle beam and all steering components

  Safe

  At Risk

  N/A

• d. Steering gear box

  Safe

  At Risk

  N/A

• e. Pitman arm

  Safe

  At Risk

  N/A

• f. Power steering

  Safe

  At Risk

  N/A

• g. Ball & socket joints

  Safe

  At Risk

  N/A

• h. Tie rods & drag links

  Safe

  At Risk

  N/A

• i. Nuts

  Safe

  At Risk

  N/A

• j. Steering System

  Safe

  At Risk

  N/A

8. Suspension

• a. Any U-bolts, spring hangers, or other axle positioning parts cracked, broken, loose or missing resulting in shifting of an axle from its normal position.

  Safe

  At Risk

  N/A

• b. Spring assembly

  Safe

  At Risk

  N/A

• c. Torque, radius or tracking components

  Safe

  At Risk

  N/A

9. Frame

• a. Frame members

  Safe

  At Risk

  N/A

• b. Tire and wheel clearance

  Safe

  At Risk

  N/A

• c. Adjustable axle assemblies (sliding sub frames)

  Safe

  At Risk

  N/A

10. Tires

• a. Tires on any steering axle of a power unit

  Safe

  At Risk

  N/A

• b. All other tires

  Safe

  At Risk

  N/A

11. Wheels and Rims

• a. Lock or slide ring

  Safe

  At Risk

  N/A

• b. Wheels and rims

  Safe

  At Risk

  N/A

• c. Fasteners

  Safe

  At Risk

  N/A

• d. Welds

  Safe

  At Risk

  N/A

12. Windshield Glazing

• Requirements and exceptions as stated pertaining to any crack, discoloration or vision reducing matter (reference 393.60 for exceptions)

  Safe

  At Risk

  N/A

13. Windshield wipers

• Any power unit that has an inoperative wiper, or missing or damaged parts that render it ineffective

  Safe

  At Risk

  N/A

14. Other

• List any other condition which may prevent safe operation of this vehicle

  Safe

  At Risk

  N/A

• List any other condition which may prevent safe operation of this vehicle

  Safe

  At Risk

  N/A

• List any other condition which may prevent safe operation of this vehicle

  Safe

  At Risk

  N/A

• List any other condition which may prevent safe operation of this vehicle

  Safe

  At Risk

  N/A

SIGNATURES

• Comments?

  Yes

  No

  N/A

• Repairs Completed?

  Yes

  No

  N/A

• Signature of Mechanic Performing Annual vehicle inspection certifying this vehicle has passed all the inspection items in accordance with 49 CFR PART 396

  Sign