HomeMy WebLinkAboutElevator Inspection ReportDEPARTMENT OF LABOR AND EMPLOYMENT
Division of Oil and Public Safety
Conveyance Section (303) 318-8550 Fax (303) 318-8534
Hydraulic Elevator Safety Test Report
Power Down Static Test Relief Valve Facility/General Information
Building Name: �d f VA.?' C l• tti�! 5
Manufacturer f)01 f<.
Capacity: 2.5 -co
Address 7 -7(7 /or_)►r i -v re 7 IA --State
Reg #
Job/Contract#: £ '6fsT5
CitYC. r"f C U f
Date: / rf 3 Z
Dutyt:.- assen er Freight
1 g
Zip. `3I 6 3 5
Rated Speed: / 60
___tri
Freight Loading Class: Cl C2 C3
Circle One 1 Acceptance ategL�r ory 1 Tests 2 Category 1 and 5 Witnessed Testing
Date Tests Performed: 2. r 20/i r'(
Was Inspector Present Yes to If "Yes" Inspector Must Sign Test Report
Piston Diameter: 4,1'' in
Relief Valve to be set at 150% or
less of the Working Pressure
Adjustment Needed Yes rtro
No Load Working PSI: / '/} psi
Adj ; stments Sealed- (AID No
Full Load Working PSI psi
Relief Valve Setting psi
Test Tag Installed. es_ No
2 Plunger Gripper Operational:1( Yes No
2 Overspeed Valve operational. C0 Yes No
Time Started / Q E/ 5
Proper Fuses Installed, - es, No
Connections Tight ,r°Yesti No
Time Ended: / / O 0
Controller Clean des- No
Jumpers Removed .,ire- - No
Elapsed Time / ti PI/ 11
Relay(s) V.sually Inspected No
Change In Car Position. Yes 1Vo) If "yes" Distance in
Oil Loss Accounted For.. -'Yes ;' No
NOTE: If any oil loss can not be accounted for, the elevator must be removed from service and the Authority Having
Jurisdiction must be notified.
Safety Devices
Stop Switches: In Car ,955: Fail Pit: evo31 Fail Top Of Car t ss Fail
Directional Limits Up. -A Fail Down .P570 Fail
Low Oil Protection NA ass Fail
Final Limits: Up: Pass Fail Down Pass Fail
Escape Hatch Contact NA Pass Fail
Low Oil Pressure Switch;. N'9, uass Fail
Car Door Restrictor: (Pass Fail
E
0
Closing Force
(Max 3010) ibf
Safety Edge. (Pass Fail
Door Guides Secure (14;DFail
Closing Time sec
Electronic Edge: ,rl a s- Fail
Door Interlocks/Gate Switch. salass Fail
Emergency
Operation
Phase I Recall NA a ass j Fail Phase I Fire Service Instruction Signage In Place es No
Phase II Operation NA .--Pg-s) Fail Phase 11 Fire Service Instruction Signage In Place. Yes 07)
Emergency Communication. NA (14;13) Fail
Alarm Bell Pass
Emergency Lights: Passe -Fir ,
,Fail -
T
Standby or Emergency Power Operation' /171.-D Fa I
/171.-D
Signatures Logs
Logs Properly Maintained / f?' No Logs Updated with this Annual safety test. ; Yes No
Fire service logs maintained. Yes No
I certify all statements are true to the best of my knowledge and that all testing was performed according to The Elevator and Escalator Certification Act
CRS § 9-5 5. Conveyance Regulations 7 CCR 1101-8 and adopted Codes:
Mechanic Name . :/::::( �, /-//j/ / Company Name 7-&-e
Signature y Date Z J jf e.0 J f �} State License #: 6.6 ' O(}c) '] 3 0
Inspector Name Company Name
Signature Date State License #
Required to be performed during acceptance inspections
Required to be performed during acceptance and Category 1 and 5 witnessed inspections
I=.,.ued 12Jan12