Attach_3_GSA-Elev.Insp.pdf

YES NO N/A

Revised 3/2012

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

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:

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.

ANNUAL & NO-LOAD TESTS

ADDRESS

MFG. NO.

MOD. YEAR LAST 5 YR

5-YEAR FIREFIGHTER'S SERVICE

FULL LOAD TESTS

CAP. LBS.# FLRS/OPNGS YESTYPE (Pass / Freight. .) INSTALL YEAR DOOR

RESTRICTION

SPEED

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

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

HOISTING

GOVERNOR

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

COMPENSATING