Special Equipment Inspection Form

• Inspection report number

• Equipment

• Type

• Serial Number

• Manufacturar

• Adres Manufacturar

• Residence manufacturar

• E-mail

• Telephone number manufacturar

• To be installed at the machine below

  Yes

  No

• Equipment & Serial Number

• Name Owner

• Adres Owner

• Residence Owner

• Telephone Number / E-mail

• Inspection date

  Date

• Contact person owner

• Location
  Address

Visuele Controle

• Indentification plate information attached

  Yes

  No

  Not Applicable

• No external damage

  Yes

  No

  Not Applicable

• Condition

  Good

  Average

  Bad

  Not Applicable

• Corrosion

  Good

  Average

  Bad

  Not Applicable

• No overload symptoms

  Yes

  No

  Not Applicable

• Working test

  Yes

  No

  Not Applicable

• No shortcomings have been observed with this work equipment, the work equipment may be used

  Yes

  No

• Inspector's name and signature

  Sign