Attachment 3 GSA Elevator Inspection Report.pdf

YES NO N/A

Revised 3/2012

HOISTING

GOVERNOR

A. THE GSA BUILDING COR WILL ENSURE THAT THE FOLLOWING DEFICIENCIES ARE

COMPENSATING

Q.E.I. NUMBER DATE OF INSPECTION

FLOOD MONITORING / CONTROL

STEEL

ROPING

ie: 1:1, etc

TYPENO. BROKEN WIRES

(per lay) IRON

EST. ADD. LIFE

(in months)

TYPE OF CONTROLTYPE OF MACHINE (Geared/Traction/ etc.)

ROPE

USED LIFE

(in months)

NUMBER SIZE

TYPE (Pass / Freight. .) INSTALL YEAR DOOR

RESTRICTION

SPEED

BTM CAR RUNBY NO LOAD PRESSURECTRWT BFR STROKECTRWT RUNBY CAR BUFFER STROKE

ANNUAL & NO-LOAD TESTS

ADDRESS

MFG. NO.

MOD. YEAR LAST 5 YR

5-YEAR FIREFIGHTER'S SERVICE

FULL LOAD TESTS

CAP. LBS.# FLRS/OPNGS YES

GENERAL SERVICES ADMINISTRATION

ELEVATOR CONTRACTORS SIGNATURE DATE BUILDINGS MANAGER SIGNATURE

BUILDING NUMBER

STATECITY

GSA CONTRACTOR NUMBER

ELEVATOR INSPECTION REPORT

BUILDING NAME

INSPECTIONS COMPLETED

MANUFACTURER

SEMIANNUAL

MAINTENANCE CONTRACTORELEVATOR NO.

DATE

II. DEFICIENCIES

CERTIFICATION: THIS FORM IS PRESCRIBED BY GSA R07 AUTHORITY - ELEVATOR MAINTENANCE, REPAIR AND INSPECTION. WHEN THE WORK DESCRIBED IN II.A ABOVE HAS BEEN COMPLETED, THE BUILDING MANAGER SHALL RETURN A SIGNED & DATED COPY OF THIS FORM TO 7PMB.

B. SERVICE CENTER MANAGEMENT (7PS) WILL ENSURE THE FOLLOWING DEFICIENCIES ARE CORRECTED

NOTE: The Semi-Annual/Annual/5year test was performed satisfactorily.

CORRECT BY:

NO

I HAVE INSPECTED THE ELEVATOR DESCRIBED ABOVE &

ITS CONDITION IS AS STATED BELOW & ON AN OVERFLOW SHEET WHERE APPLICABLE.

TYPE OF OPERATION (SELL. COLL., ETC.)

CORRECTED BY THE ELEVATOR CONTRACTOR BY THE DATE INDICATED

RELIEF PRESSURETOP RUNBY (hydro)

INSPECTOR'S NAME

I. CONDITION OF ROPES

NUMBER SIZE

NO. BROKEN WIRES

(per lay)

CORRECTED BY THE ELEVATOR CONTRACTOR BY THE DATE INDICATED

GOVERNOR

HOISTING

COMPENSATING

A. THE GSA BUILDING COR WILL ENSURE THAT THE FOLLOWING DEFICIENCIES ARE

II. DEFICIENCIES

BUILDINGS MANAGER SIGNATURE DATE

CERTIFICATION: THIS FORM IS PRESCRIBED BY GSA R07 AUTHORITY - ELEVATOR MAINTENANCE, REPAIR AND INSPECTION. WHEN THE WORK DESCRIBED IN II.A ABOVE HAS BEEN COMPLETED, THE BUILDING MANAGER SHALL RETURN A SIGNED & DATED COPY OF THIS FORM TO 7PMB.

NOTE: The Semi-Annual/Annual/5year test was performed satisfactorily.

CORRECT BY:

B. SERVICE CENTER MANAGEMENT (7PS) WILL ENSURE THE FOLLOWING DEFICIENCIES ARE CORRECTED

I HAVE INSPECTED THE ELEVATOR DESCRIBED ABOVE &

ITS CONDITION IS AS STATED BELOW & ON AN OVERFLOW SHEET WHERE APPLICABLE

STEEL

ROPING TYPE

GENERAL SERVICES ADMINISTRATION

ELEVATOR CONTRACTORS SIGNATURE DATE

I. CONDITION OF ROPES

Q.E.I. NUMBER

IRON

DATE OF INSPECTION

ROPE

USED LIFE

(in months)ie: 1:1, etc

TYPE OF OPERATION (SELL. COLL.,ETC.)

INSPECTOR'S NAME

BTM CAR RUNBYTOP RUNBY (hydro) CTRWT RUNBY CTRWT BFR STROKE NO LOAD PRESSURECAR BUFFER STROKE

FLOOD MONITORING / CONTROLTYPE OF MACHINE (Geared/Traction/ etc.)

RELIEF PRESSURE

TYPE OF CONTROL

LAST 5 YRINSTALL YEARTYPE (Pass / Freight. .) SPEEDMOD. YEAR CAP. LBS.# FLRS/OPNGS YES

NO

DOOR

RESTRICTION

MAINTENANCE CONTRACTOR GSA CONTRACTOR NUMBERMFG. NO.

ELEVATOR INSPECTION REPORT

FULL LOAD TESTS

SEMIANNUAL ANNUAL & NO-LOAD TESTS

BUILDING NUMBER

CITYADDRESS

BUILDING NAME

STATE

INSPECTIONS COMPLETED

ELEVATOR NO.

5-YEAR FIREFIGHTER'S SERVICE

MANUFACTURER

HOISTING

GOVERNOR

A. THE GSA BUILDING COR WILL ENSURE THAT THE FOLLOWING DEFICIENCIES ARE

COMPENSATING

Q.E.I. NUMBER DATE OF INSPECTION

FLOOD MONITORING / CONTROL

STEEL

ROPING

ie: 1:1, etc

TYPENO. BROKEN WIRES

(per lay) IRON

TYPE OF CONTROLTYPE OF MACHINE (Geared/Traction/ etc.)

ROPE

USED LIFE

(in months)

NUMBER SIZE

TYPE (Pass / Freight. .) INSTALL YEAR DOOR

RESTRICTION

SPEED

BTM CAR RUNBY NO LOAD PRESSURECTRWT BFR STROKECTRWT RUNBY CAR BUFFER STROKE

ANNUAL & NO-LOAD TESTS

ADDRESS

MFG. NO.

MOD. YEAR LAST 5 YR

5-YEAR FIREFIGHTER'S SERVICE

FULL LOAD TESTS

CAP. LBS.# FLRS/OPNGS YES

GENERAL SERVICES ADMINISTRATION

ELEVATOR CONTRACTORS SIGNATURE DATE BUILDINGS MANAGER SIGNATURE

BUILDING NUMBER

STATECITY

GSA CONTRACTOR NUMBER

ELEVATOR INSPECTION REPORT

BUILDING NAME

INSPECTIONS COMPLETED

MANUFACTURER

SEMIANNUAL

MAINTENANCE CONTRACTORELEVATOR NO.

DATE

II. DEFICIENCIES

CERTIFICATION: THIS FORM IS PRESCRIBED BY GSA R07 AUTHORITY - ELEVATOR MAINTENANCE, REPAIR AND INSPECTION. WHEN THE WORK DESCRIBED IN II.A ABOVE HAS BEEN COMPLETED, THE BUILDING MANAGER SHALL RETURN A SIGNED & DATED COPY OF THIS FORM TO 7PMB.

B. SERVICE CENTER MANAGEMENT (7PS) WILL ENSURE THE FOLLOWING DEFICIENCIES ARE CORRECTED

NOTE: The SemI-Annual / Annual / 5 year test was performed satisfactorily.

CORRECT BY:

NO

I HAVE INSPECTED THE ELEVATOR DESCRIBED ABOVE &

ITS CONDITION IS AS STATED BELOW & ON AN OVERFLOW SHEET WHERE APPLICABLE

TYPE OF OPERATION (SELL. COLL., ETC.)

CORRECTED BY THE ELEVATOR CONTRACTOR BY THE DATE INDICATED

RELIEF PRESSURETOP RUNBY (hydro)

INSPECTOR'S NAME

I. CONDITION OF ROPES

Revised 3/2012GENERAL SERVICES ADMINISTRATION

BY THE ELEVATOR CONTRACTOR PRIOR TO THE "CORRECT BY" DATE

ELEVATOR INSPECTION REPORT

OVERFLOW SHEET

Elevator #:

II. DEFICIENCIES (Cont.)

A. THE GSA BUILDING MANAGER WILL ENSURE THAT THE FOLLOWING DEFICIENCIES ARE CORRECTED

BUILDING NUMBER

STATECITYADDRESS

BUILDING NAME

B. MAINTENANCE MANAGEMENT WILL ENSURE THAT THE FOLLOWING DEFICIENCIES ARE CORRECTED