CDRL 0003_SAFETY CERTIFICATION_USNS SACAGAWEA.pdf

CONTRACT DATA REQUIREMENTS LIST Form Approved

(1 Data Item) 0MB No. 0704-0188

The public reporting burden for this collection of information is estimated to average 110 hours per response, including the lime for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0701-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington, VA 22202-4302. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if ii does not display a currently valid 0MB control number. Please DO NOT RETURN your form to the above address. Send completed form to the Government Issuing Contracting Officer for the ContracVPR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

CLIN 0003 TDP TM --- OTHER

I

E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO.

D. SYSTEM/ITEM

MHE Forklifts

2. TITLE OF DATA ITEM 3. SUBTITLE

C0001 MHE Safety Certification

4. AUTHORITY (Data Acquisition Document No.)

5. CONTRACT REFERENCE 6. REQUIRING OFFICE

sow Para 6.6 N32205

7. DD250 REQ 9. DIST STATEMENT 10. FREQUENCY 12. DATE OF FIRST SUBMISSION 14. DISTRIBUTION

REQUIRED N/A ASGEN SEE BLOCK 16

8.APP CODE 11. AS OF DATE 13. DATE OF SUBSEQUENT

N/A SUBMISSION

N/A N/A

16. REMARKS

Service provider shall submit a safety certification on each forklift/pallet jack asset to Military Sealift Command, Norfolk, VA. This safety certification denotes the applicable 18-month periodic test shall identify the overall condition of each asset and list all necessary repairs required to meet the operational and safety specifications of NAVSEA SWO23-AH-WHM-010 EIGHT REVISION, MHE Safety Certification Form.

(CDRL 0003).

G. PREPARED BY H.DATE I. APPROVED BY N441 Acting

DD FORM 1423-1, AUG 96 (EG) PREVIOUS EDITION MAY BE USED.

b. COPIES

a. ADDRESSEE Final Draft

Reg Repro

MHE HELP DESK

MSC MHEOHE@US.NA VY.MIL

15. TOTAL

J. DATE

Page_1_of_1_Pages Designed using Perform Pro, WHS/DIOR, Aug 96

17. PRICE GROUP

18. ESTIMATED

TOTAL PRICE

C XXXX

SEE BLOCK 16

NAVSEA SW023-AH-WHM-010 EIGHTH REVISION

6-5

MARKINGS

FUEL SYSTEM

NEUTRAL START SWITCH

(Fueled MHE)

WARNING DEVICES

(Powered MHE)

SPARK EMISSION

(Powered MHE)

STATIC DISCHARGE

(Electric and HS/Ordnance Pallet Truck)

___OHMS ____ OHMS

CARRIAGE REACH & ROLLER

(Reach & Tier)

DRIVE CONTROL

(Powered Pallet Trucks)

BRAKE

(Except Straddle Carriers and Manual Pallet Trucks)

BRAKE

(Straddle Carrier)

OPERATIONAL WEIGHT TEST

(Forklift Trucks)

OPERATIONAL WEIGHT TEST

(Powered Pallet Trucks)

KING PIN (Straddle Carrier)

LIFTING WEIGHT TEST

(Straddle Carrier)

OVERLOAD WEIGHT TEST

(Except Pallet Trucks and Straddle Carriers)

LIFT EYES

(Except Straddle Carriers)

THIS IS TO CERTIFY THAT THE ABOVE MHE WAS INSPECTED AND TESTED IN ACCORDANCE WITH NAVSEA SW023-AH-WHM-010.

MECHANIC/MAINTENANCE PROVIDER:

PRINT FULL NAME SIGNATURE DATE

CERTIFIED BY:

PRINT FULL NAME SIGNATURE DATE

THIS 18 MONTH CERTIFICATION EXPIRES ON:

MONTH/YEAR

FIGURE 6-1. MHE Safety Certification Form

Click Here to reproduce and annotate this form