CDRL A0003 SAFETY CERTIFICATION.pdf

CONTRACT DATA REQUIREMENTS LIST Form Approved

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

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

CDRLA0003 TDP TM --- OTHER

E. CONTRACT/PR

NO. IN3220522Q0132

F. CONTRACTOR

1. DATA ITEM NO.

D. SYSTEM/ITEM

MHE Forklifts

2. TITLE OF DATA ITEM 3. SUBTITLE

0003 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 As Required As Required

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

N/A SUBMISSION

As Required As Required

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 A0003).

G. PREPARED BY H.DATE I. APPROVED BY

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

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

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