Attachment I - Monthly Summary Report.pdf

Contract Requirements Date FM Initials or Comments

Logbook completed with all required information (Y/N):

All Service Ticket(s) for the month signed & attached (Y/N):

Reference Library Maintained (Y/N):

Condition Report (Quarterly) - completed and submitted (Y/N):

Services Provided Information Fill In

Information FM Initials or Comments

Date of Previous Monthly Service:

Number of Service Calls:

Hours Spent on Service Calls (Provide total hours and hours per call):

Monthly Scheduled Service Visit for Preventative Maintenance (date):

Hours Spent on Scheduled Preventative Maintenance by the Contractor:

Equipment Cleaned by the Contractor (list details below):

Debris Removed after Service (Y/N):

List any Inspections During the Service Period:

Equipment Painted by the Contractor (list details below):

Monthly Equipment Inspection (provide information below):

Were all Entrapments discussed (Y/N):

Car(s) Out of Service Date Task or Reason Elevator Number:

Reason:

Time Out of Service:

Time Back in Service:

Total Days Out of Service:

Tasks Performed:

Resolution of Problems:

List of All Equipment Cleaned (include Elevator Number & Room): Date Cleaned Part(s) Cleaned

List of All Equipment Painted (include Elevator Number & Room): Date Painted Part(s) Painted

Detail of Services Listed in Logbook (I.e., oil or fluid added, bulbs changed): Date Task or Reason

Attachment I - Monthly Summary Report Elevator Preventative Maintenance, Repair, Inspection, and Testing Services

ITN No. DMS-22/23-089 (Must be submitted with Monthly Invoice)

Invoice Amount:

Invoice Date:

Please use Comments Section below to provide details of problems, solutions, and comments.

Monthly Summary Report for the Month of:

Requirements

Facility:

Vendor:

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Credits to Be Issued: Reason Amount

Certification Information Date Inspected Signature Safety Certification Letter (Annual) Certificates of Competency (Section 399.01, Florida Statutes) Electric Traction Elevator Safety Test (Annual) Hydraulic or Traction Elevator Safety Test (Annual) Three-Year Hydraulic Safety Test Date (hydraulic elevators) Five-Year Full Load Safety Test Date

Required Signatures: Name Signature Assigned Contractor Technician:

Inspection by Senior Representative:

Facility Manager's or Designee's Signature:

Senior Representative's Signature:

Monthly Inspection Issues: Dates

Repair Plan for any Issues: Dates

Labor and Material Costs, Estimated Time to Obtain Parts, Time to Repair: Dates

Comments and Explanations: Dates

Please use Comments Section below to provide details of problems, solutions, and comments.

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