TE-10-3_GSA_FORM_376_11-1967.pdf
GSA Form Nov 1967 PDF 282 KB Posted
- Attached to
- FACILITIES INVESTMENT SERVICES_REGION 6 FOR THE 63d READINESS DIVISION (RD) US ARMY RESERVES
- Solicitation number
- W9127S21Q0056
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Other versions and copies of GSA Form 376
| File | Revision | Posted | Attached to |
|---|---|---|---|
| TE-10-3_GSA_FORM_376_11-1967.pdf Same revision and size as this file | Nov 1967 | FACILITY INVESTMENT SERVICES FOR THE 63RD READINESS DIVISION (RD) FOR REGION 5 | |
| A.03.09 GSA Form 376.pdf Same revision and size as this file | Revision not stated | Elevator Inspections and Maintenance Services |
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Text version
ELEVATOR INSPECTION REPORT
(Including Escalators and Dumbwaiters) (Read instructions on reverse before preparing report)
BUILDING
STATECITYSTREET ADDRESS
DATE INSPECTION ORDERED
MECHANIC'S SIGNATURE
INSPECTOR'S SIGNATURE INSPECTOR'S TITLE
B. LIST REPAIR AND MAINTENANCE ITEMS BELOW THAT ARE OUTSIDE THE SCOPE OR RESPONSIBILITY OF THE BUILDINGS MANAGER OR CUSTODIAN.
BUILDINGS MANAGER'S SIGNATURE DATE
DATE
All elevators, escalators, and dumbwaiters in this building have been inspected by the undersigned inspector on the date noted, and were found to be in a satisfactory condition, except as noted below.
A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING.
(List items below that can be properly performed by force account.)*
THE WORK DESCRIBED ABOVE HAS BEEN COMPLETED, AND THE EQUIPMENT IS READY FOR REINSPECTION, IF REQUIRED
DATE INSPECTION DATE INSPECTION
CERTIFICATES SIGNEDSTARTED:
COMPLETED:
PASSENGER FRT. OR SERV. ESCALATOR DUMBWAITER
REGION
NUMBER OF UNITS IN BUILDING
GSA FORM 376 (11-67)* (Use reverse when more space is required.)GENERAL SERVICES ADMINISTRATION
INSTRUCTIONS
TO
a. Design and Construction Division
b. Buildings Manager - to be forwarded through the regional Buildings Management Division. (One copy to be signed by the mechanic and the Buildings Manager upon completion of the work listed in Section A of the report, and returned to the inspector.
As determined by regional requirements
NUMBER OF COPIES
1. A separate report shall be made for each building for which PBS is responsible for elevator inspections.
2. Distribution of copies:
GSA FORM 376 BACK (11-67)
ELEVATOR INSPECTION REPORT
(Including Escalators and Dumbwaiters) (Read instructions on reverse before preparing report)
BUILDING
STATE
CITY
STREET ADDRESS
DATE INSPECTION ORDERED
MECHANIC'S SIGNATURE
INSPECTOR'S SIGNATURE
INSPECTOR'S TITLE
B. LIST REPAIR AND MAINTENANCE ITEMS BELOW THAT ARE OUTSIDE THE SCOPE OR RESPONSIBILITY OF THE BUILDINGS MANAGER OR CUSTODIAN.
BUILDINGS MANAGER'S SIGNATURE
DATE
DATE
All elevators, escalators, and dumbwaiters in this building have been inspected by the undersigned inspector on the date noted, and were found to be in a satisfactory condition, except as noted below.
A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING.(List items below that can be properly performed by force account.)* THE WORK DESCRIBED ABOVE HAS BEEN COMPLETED, AND THE EQUIPMENT IS READY FOR REINSPECTION, IF REQUIRED
DATE INSPECTION
DATE INSPECTION CERTIFICATES SIGNED
STARTED:
COMPLETED:
PASSENGER
FRT. OR SERV.
ESCALATOR
DUMBWAITER
REGION
NUMBER OF UNITS IN BUILDING
GSA FORM 376 (11-67)
* (Use reverse when more space is required.)
GENERAL SERVICES ADMINISTRATION
INSTRUCTIONS
TO
a. Design and Construction Division
b. Buildings Manager - to be forwarded through the regional Buildings Management Division. (One copy to be signed by the mechanic and the Buildings Manager upon completion of the work listed in Section A of the report, and returned to the inspector.
As determined by regional requirements 2
NUMBER OF COPIES
1. A separate report shall be made for each building for which PBS is responsible for elevator inspections. 2. Distribution of copies:
GSA FORM 376 BACK (11-67)
8.2.0.3062.1.452232.445150
| BUILDING: |
| STREET ADDRESS: |
| INSPECTOR'S TITLE: |
| A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING. (List items below that can be properly performed by force account.)*: |
| B. LIST REPAIR AND MAINTENANCE ITEMS BELOW THAT ARE OUTSIDE THE SCOPE OR RESPONSIBILITY OF THE BUILDINGS MANAGER OR CUSTODIAN.: |
| CITY: |
| STATE: |
| REGION: |
| DATE INSPECTION ORDERED. Enter 2 digit month, 2 digit day and 4 digit year.: |
| DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| DATE. Enter 2 digit month, 2 digit day and 4 digit year.: |
| DATE INSPECTION CERTIFICATES SIGNED. Enter 2 digit month, 2 digit day and 4 digit year.: |
| DATE INSPECTION STARTED. Enter 2 digit month, 2 digit day and 4 digit year.: |
| DATE INSPECTION COMPLETED. Enter 2 digit month, 2 digit day and 4 digit year.: |
| NUMBER OF UNITS IN BUILDING. PASSENGER: |
| NUMBER OF UNITS IN BUILDING. FRT. OR SERV.: |
| NUMBER OF UNITS IN BUILDING. ESCALATOR: |
| NUMBER OF UNITS IN BUILDING. DUMBWAITER: |
| BUILDINGS MANAGER'S SIGNATURE. DIGITAL SIGNATURE.: |
| A. THE BUILDING MANAGER OR CUSTODIAN IS REQUESTED TO HAVE THE FOLLOWING WORK PERFORMED ON THE EQUIPMENT IN THIS BUILDING. (List items below that can be properly performed by force account.)* Continued from page 1.: |
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