CDRL 0005 Aerial Work Platform Certification Form.pdf

SAFETY INSPECTION AND WEIGHT TEST CERTIFICATION

OF AERIAL MAINTENANCE PLATFORM

USN NO.

2519002

COMMAND:

USNS HENRY J

KAISER

MANUFACTURER:

GENIE

EQUIPMENT TYPE:

AERIAL MAINTENANCE PLATFORM

SERIAL NUMBER:

300026065

BASKET # MODEL: MODEL YEAR: HOUR METER: CAPACITY:

500 Lbs. Unrestricted

CERTIFICATION:

This is to certify that inspections and tests have been conducted in accordance with procedures set forth in the current NAVFAC P-300 and applicable manufactures technical manual. It is further certified that the above Aerial Maintenance Platform is satisfactory to lift its rated capacity and is fully operational.

• Certified for 500 Lbs., (500 lb. un-restricted). Percent testing 100% .

• Not certified for electrical or hot work

X Annual Certification Special Certification Certification Date: Expiration Date: Inspector (printed name)

Inspector (signature) Date

MHE-11-2010

REVISED 07/19/10