CDRL 0005 AERIAL WORK PLATFORM CERT FORM (AWP).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.

17. PRICE GROUP

4. AUTHORITY (Data Acquisition Document No.)

sow

5. CONTRACT REFERENCE

1 Para 3.10 and 3.11.1

6. REQUIRING OFFICE

N32205

18. ESTIMATED

TOTAL PRICE

7. DD250 REQ

N/A

8. APP CODE

9. DIST STATEMENT

REQUIRE

SEE

BLOCK

10.FREQUENCY

ASGEN

12.DATE OF FIRST SUBMISSION

SEE BLOCK 16

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

11.AS OF DATE

N/A

13.DATE OF SUBSEQUENT

SUBMISSION

N/A

Final Draft

Reg Repro

16.REMARKS

A finalized MHE Inspection Form filled out IAW, NAVSUP PUBLICATION 538 SIXTH

REVISION for each unit identifying the current operational condition, status of safety devices and all required repairs. The hard copy form and electronic copy sent via email, will be provided to the MSC N44 MHE Help Deck (CDRL 0003)

MHE Help Desk

MSC MHEOHE@US.NA VY.MIL

15. TOTAL

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

J.DATE

DD FORM 1423-1, AUG 96 (EG) PREVIOUS EDITION MAY BE USED. Paae 1 of 4 Pages Designed using Perform Pro, WHS/DIOR, Aug 96

A. CONTRACT LINE ITEM NO.

CLIN 0005

B. EXHIBIT

E

C. CATEGORY:

TDP TM --- OTHER XXXX

D. SYSTEM/ITEM E. CONTRACT/PR NO.

MHE Hyster Forklifts

F. CONTRACTOR

3.SUBTITLE 1.DATA ITEM NO.

E0003

2. TITLE OF DATA ITEM

AERIAL WORK PLATFORM CERTIFICATION FORM

mailto:MHEOHE@US.NA

SAFETY INSPECTION AND WEIGHT TEST CERTIFICATION

OF AERIAL MAINTENANCE PLATFORM

USN NO.

2500003

COMMAND:

USNS SACAGAWEA

MANUFACTURER:

GENIE

EQUIPMENT TYPE:

AERIAL MAINTENANCE PLATFORM

SERIAL NUMBER:

Z452507-32558

MODEL:

Z-45/25J IC

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