6167 TEMPLET.doc

REPORT OF TEST OF ELEVATOR GOVERNOR AND

SAFETY DEVICE

DATE OF TEST

Region No._________(138)

Veterans Administration Central Office

Washington, D.C. 20420

NAME AND LOCATION OF STATION

TEST (Check)

[ ] ANNUAL

[ ] FIVE YEARS (See contract specifications) [ ] THREE YEARS (HYDRAULIC) (See contract specifications)

BUILDING NAME AND NO.

ELEVATOR NUMBER AND TYPE

RATED CAPACITY

LBS: PERSONS:

MAUFACTURER SERIAL NO. AND YEAR INSTALLED

RATED SPEED (FPM)

ACTUAL SPEED (FPM-TACH.)

SAFETY (See rule 205.5 code A17/1-1971 and below) OTHER

[ ] TYPE A [ ] TYPE B [ ] TYPE C [ ] BROKEN ROPE [ ] (SPECIFY)

IS SAFETY VALVE PROPERLY SET?

[ ] YES [ ] NO

DISTANCE CAR SLIDES AFTER SAFETY IS APPLIED TO RAIL

FT IN.

MARK ON RAIL

LEFT RIGHT

[ ] RAIL [ ] RAIL FT IN

DISTANCE GOVERNOR ROPE SLIDES THROUGH JAWS.

FT IN

CONDITION OF GOVERNOR JAWS

[ ] GOOD [ ] FAIR [ ] POOR

ROPE FROM DRUM IN TEST

FT IN

NO. OF TURNS REMAINING ON DRUM

WAS PLATFORM OUT OF LEVEL AFTER TEST?

[ ] YES [ ] NO (If “Yes,” how much) WAS CAR FRAME SPRUNG AFTER TEST? (If “Yes,” specify whether left or right)

[ ] YES [ ]NO

DAMAGE RESULTING FROM TEST

DID DAMAGE OCCUR TO THE FOLLOWING?

CAR GUIDES ROPES RAILS CLAMPS BRACKETS SAFETY

[ ] YES [ ] NO [ ] YES [ ] NO [ ] YES [ ] NO [ ] YES [ ] NO [ ] YES [ ] NO [ ] YES [ ] NO

ANY LOSS OF BUFFER OIL IN TYPE C SAFETIES?

[ ] YES [ ] NO

WAS RELEASING CARRIER PROPERLY ADJUSTED?

[ ]YES [ ] NO

ARE GUIDES FIRMLY SECURED TO CAR FRAMES?

[ ] YES [ ] NO

DID SAFETY PARTS ON CAR FRAME SHOW FOREIGN OBSTRUCTION? NO

[ ] RUST [ ] LACK OF ATTENTION

[ ] CORROSION [ ] DAMPNESS [ ] OTHER (other please specify)

GOVERNOR

ALL PARTS FREE FROM—

PAINT? RUST? CORROSION?

[ ] YES [ ] NO [ ] YES [ ] NO [ ] YES [ ] NO

WAS GOVERNOR PROPERLY LUBRICATED?

[ ] YES [ ] NO

[ ] YES [ ] NO

DO BEARING OR GEARS SHOW EXCESSIVE WEAR?

[ ] YES [ ] NO

WAS TENSION IDLER FREE IN FRAME GUIDES AND IN ITS SHAFT?

[ ] YES [ ] NO

IS PROPER SIZE GOVERNOR ROPE BEING USED?

[ ] YES [ ] NO

IS THE PROPER TYPE OF ROPE USED?

[ ] YES [ ] NO

REMARKS

NOTE: SAFETIES SHALL BE SUBJECT TO AN ANNUAL RUNNING TES WITH NO LOAD IN THE CAR AS FOLLOWS:

APPLICABLE RULE OF ANSI.—CODE

TEST OF SAFETIES A17.1 1971

1. TUPE A, B, OR C GOVERNOR – OPERATED SAFETIES. 1001.4a1

2. WOOD GUIDE GOVERNOR – OPERATED SAFETIES 1001.4a1

3. TYPE A AND WOOD GUIDE SAFETIES WITHOUT GOVERNORS OPERATED ONLY AS A RRESULT OF THE BREAKING OR SLACKENING OF THE HOISTING ROPES 1001.4a3

CONTRACT NO.

NAME OF CONTRACTING COMPANY

SIGNATURE OF INSPECTING OFFICER

WE CERTIFY that the contractor has complied with all requirements of the contract and specifications

Use reverse for any Remarks and/or recommendations

VA FORM 10-6167 SUPERSEDES VA FORM 10-6167, NOV 1961

MAY 1972 WHICH WILL NOT BE USED