SAMPLE REPORT

Acme Company 1 Boston Road

Lawrence, MA 01841

Crane & Hoist Inspection Report August 2015

SAMPLE

Crane & Hoist Inspection Report

Table of Contents

SAMPLE

1. Repair quote and Inspection Reports

2. A- Crane Inspection Reports

3. B-Hand Chain Fall Inspection Reports

4. C-Electric Chain Hoist Inspection Reports 5. CS-Chain/Sling Inspection Sheet

5. D-Electric Cable Hoist Inspection Reports

6. E-Blank Inspection Reports 7. F-Charging Bucket Inspection Report 8. G-Pneumatic Chain Hoist Inspection Report

SAMPLE

March 2015 Mr. John Doe Acme Company 1 Boston Road Lawrence, MA 01841 Dear Mr. Doe, As a result of our recent inspections, we found the following deficiencies. We are pleased to offer you this quotation on the material and labor that are necessary to bring your equipment up to safe and efficient working levels. Item #1 – IR #0008A Main Engine Room BECH Bridge S/N 351295 C-M Hoist L-1965 KM

A. Replace push button enclosure (1) B. Replace push button boots (8) C. Replace push button labels

Item #2. - IR#0004B Maintenance Rack Ratcliff S/N K1574

A. Replace safety latch (ordered 02-10-04) (2) B. Provide spare latches (6)

Materials: $ 325.00 Labor: $ 680.00 Travel: $ 100.00 Total: $1,105.00 This work is to be performed in a timely manner upon procurement of necessary materials from vendors. Lead time on material is 7 – 10 Days. The aforementioned pricing reflects the issuance of one purchase order to perform the entire work scope. If you choose to change the work scope, a revised quotation will follow to accommodate the changes. All work to be performed during normal working hours, in a reasonably clear area, by our own licensed electricians and servicemen.

SAMPLE

2 of 2

This price does not include a manlift/forklift to perform the repairs. If a manlift/forklift is required and not available on site, we will provide one to be billed at an additional cost. Freight will be billed at cost. Piquette and Howard reserves the right to determine whether or not a customer-supplied manlift is adequate to perform the work scope. This insures safe and efficient working conditions. The price quoted is firm for thirty (30) days and does not reflect sales taxes. If the project is tax exempt, a tax exempt certificate must accompany and purchase order. If the tax is applicable, it will be added to and made part of the contract amount. Terms are net thirty (30) days; subject to credit approval. If you should have any questions or require additional information, please do not hesitate to contact us. Regards, Dale Purdy Service Manager/Crane and Hoist Division SAMPLE

IR # A

OVERHEAD CRANES

CRANE INSPECTION AND CHECKLISTMEETS ANSI B30-2.0

ANDO.S.H.A. SECTION 1910.179

COMPANY NAME DATE

STREET ADDRESS JOB # P.O. #

CITY/TOWN STATE ZIP

CONTACT PERSON PHONE #

MANUFACTURER LOCATION CUST. I.D. #

COMMENTS:

Copy of Report Issued Equipment left in Service Removed from service, locked out and tagged out, owner assumed responsibility

DATE:Piquette & Howard Serviceman (Signature)

DATE:Piquette & Howard Serviceman (Print)

DATE:CUSTOMER ACCEPTANCE (Signature)

DATE:CUSTOMER (Print)

222 Plaistow RoadPlaistow, NH 03865Tel: (603) 382-3182Fax: (603) 382-3582

CRANE IDENTIFICATION

CAPACITY: MAIN HOIST CAPACITY: AUXILIARY HOIST CAPACITY: BRIDGE

SPAN BRIDGE TYPE: HOIST TYPE:

TOP RUNNING UNDERHUNG GANTRY TOP RUNNING UNDERHUNG

SERIAL NUMBER / BRIDGE SERIAL NUMBER / M/H SERIAL NUMBER / A/H

POWER SUPPLY: A.C. VOLTS D.C. VOLTS CONTROL VOLTAGE LIFT

ACCESS TO EQUIPMENT LOAD TEST MPT

SAMPLE

CRANE SURVEY CHECKLISTTROLLEYSECTION

Check Column

CAB-FESTOONCONDUCTORS

Check Column

GO

OD

DE

FE

CT

IVE

GO

OD

DE

FE

CT

IVE

COMMENTS COMMENTS

Driver wheelsIdler wheelsAxles – CouplingsShaftsAxle pinionMotorSlip ringsBrushesBrushholderBrakesGearcaseControllersResistorsSoft StartFreq driveContact tipsPush Button Station: Type Hubbel (Small gear case)CasePush ButtonsLabelsPendant SupportStrain chainNo. buttonsPendant CordCord connectorsOn Off switchLightSelector switchRadioBalancerCord ReelRadio Control: TypeTransmitterReceiverOperation

Cab Section:Bridge ControlMain hoist controlAux. hoist control#1 trolley control#2 trolley controlBridge brake pedalGlassLightStart stop stationMain line disconnectMain line contactorTransformerCleanliness

Festoon Section:TrackFlat cableRound cableFestoon trolleysHangersHanger supportsEnd stops TaglineCable connectorsControl trolleyTow trolleyTiller rope – Tag LineTow bar

Conductor Section:Runway conductorsRunway collectorsRunway splice coversRunway end capsRunway power feedsRunway collector shoesBridge conductorsBridge collectorsBridge splice coversBridge end capsBridge power feedsBridge collector shoes

A

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lisaLine

CRANE SURVEY CHECKLISTBRIDGESECTION

Check Column

HOISTSECTION

Check Column

GO

OD

DE

FE

CT

IVE

GO

OD

DE

FE

CT

IVE

COMMENTS COMMENTS

AlignmentGirdersRailsWalks - LaddersEnd trucksDriver wheelsIdler wheelsRail SweepsBumpersAxles-CouplingsShafts/BearingsAxle pinionsKeys-KeywaysBridge gear boxBrakes MotorSlip ringsBrushesBrush holdersResistorsSoft startFreq. driveMotor controllersContact tipsRunwayJ-Bolts – clipsLightsHorn or bellLubricationCapacity markings

GO

OD

DE

FE

CT

IVE

MAIN AUX

Load BlockLoad HookSheavesSafety latchesWire ropeRope anchorsRope GuideReavingDrumGear Boxes (2)MotorBrushesBrush holdersSlip ringsResistorsFreq. DriveMotor ControllerContact TipsElect. BrakeLoad brakeGeared limitPaddle limitLubricationOil leaksCapacity markings

A

SAMPLE

HAND CHAIN FALL INSPECTION REPORTSCUSTOMER DATE CUSTOMER P.O. JOB NUMBER

ADDRESS CITY STATE ZIP

CONTACT MANUFACTURER MODEL NO. SERIAL NO. CUSTOMER I.D. NO.

LOCATION ACCESS CAPACITY LIFT

MOUNTING LOAD TEST MPT CNTRL VOLT. VOLTAGE PHASE

DESCRIPTION GOOD DEFECTIVE COMMENTS

COMMENTS:

Copy of Report Issued Equipment left in Service Removed from service, locked out and tagged out, owner assumed responsibility

DATE:Piquette & Howard Serviceman (Signature)

DATE:Piquette & Howard Serviceman (Print)

DATE:CUSTOMER ACCEPTANCE (Signature)

DATE:CUSTOMER (Print)

222 Plaistow RoadPlaistow, NH 03865Tel: (603) 382-3182Fax: (603) 382-3582

IR # B

Hand Wheel CoverHand WheelHand ChainRatchetBrake DiscPawlPawl SpringDrive SpindleGear CoverGearsLoad WheelLoad ChainChain GuidesDead End Stud & LinkLoad Wheel GantryLoad HookTop Hook Safety LatchLubricationTrolleyTrolley lugsCapacity Markings

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ELECTRIC CHAIN HOIST INSPECTION REPORTSCUSTOMER DATE CUSTOMER P.O. JOB NUMBER

ADDRESS CITY STATE ZIP

CONTACT MANUFACTURER MODEL NO. SERIAL NO. CUSTOMER I.D. NO.

LOCATION ACCESS CAPACITY LIFT

MOUNTING LOAD TEST MPT CNTRL VOLT. VOLTAGE PHASE

DESCRIPTION GOOD DEFECTIVE COMMENTS

COMMENTS:

Copy of Report Issued Equipment left in Service Removed from service, locked out and tagged out, owner assumed responsibility

DATE:Piquette & Howard Serviceman (Signature)

DATE:Piquette & Howard Serviceman (Print)

DATE:CUSTOMER ACCEPTANCE (Signature)

DATE:CUSTOMER (Print)

222 Plaistow RoadPlaistow, NH 03865Tel: (603) 382-3182Fax: (603) 382-3582

IR # C

Chain Chain guide/ContainerLift wheelLoad wheelLoad hook/Block Top hook – LugSafety latchHoist elec. brakeHoist load brakeTransformerPaddle limit clutchGeared limitCentrifical switchCapacitorsContactorsContact tipsHoist motorCollectorsPower cordCord reelPendant cordPushbutton: type Gear caseTrolley motorTrolley controlTrolley brakeTrolley wheelsTrolley lugsBridge motor JibBridge control BracingBridge brake CapacityBridge wheels

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222 Plaistow RoadPlaistow, NH 03865Tel: (603) 382-3182Fax: (603) 382-3582

COMPANY NAME _____________________________________________________

ADDRESS ___________________________________________________________

CITY & STATE _______________________________________________________

CONTACT ___________________________________________________________

SURVEY BY _________________________________________________________

DATE _______________________________________________________________

JOB# _____________________________ P.O. _____________________________

CHAIN/SLING INSPECTION SHEET

LOCATION MANUFACTURER SERIAL NO. TYPE SIZE REACH

CONDITION

O.K

.

Rem

oved

from

se

rvic

e

Hoo

kO

peni

ng

Mis

sing

Tag(

s)

MP

T

COMMENTS

1

2

3

4

5

6

7

8

9

Serviceman Signature ____________________________________________________

Customer Signature ______________________________________________________________

Customer Print Name ____________________________________________________________

CS #

SAMPLE

ELECTRIC CABLE HOIST INSPECTION REPORTSCUSTOMER DATE CUSTOMER P.O. JOB NUMBER

ADDRESS CITY STATE ZIP

CONTACT MANUFACTURER MODEL NO. SERIAL NO. CUSTOMER I.D. NO.

LOCATION ACCESS CAPACITY LIFT

MOUNTING LOAD TEST MPT CNTRL VOLT. VOLTAGE PHASE

DESCRIPTION GOOD DEFECTIVE COMMENTS

COMMENTS:

Copy of Report Issued Equipment left in Service Removed from service, locked out and tagged out, owner assumed responsibility

DATE:Piquette & Howard Serviceman (Signature)

DATE:Piquette & Howard Serviceman (Print)

DATE:CUSTOMER ACCEPTANCE (Signature)

DATE:CUSTOMER (Print)

222 Plaistow RoadPlaistow, NH 03865Tel: (603) 382-3182Fax: (603) 382-3582

IR # D

Load CableRope GuideDrumSheaveLoad HookSafety LatchHoist Electric BrakeHoist Mechanical BrakeTransformerPaddle LimitGeared LimitCentrifical Switch VFD DriveCapacitorsContact TipsHoist MotorCollectorsPower CordCord ReelPendant Cord Trans CasePushbutton: type RadioGear CaseTrolley Motor Tractor Drv.Trolley Control Tractor Drv.Trolley Brake Tractor Gear BoxTrolley WheelsTrolley lugsBridge Motor MonorailBridge Control Elec. SwitchBridge Brake Manual SwitchBridge Wheels Cap/Warning tags

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CUSTOMER DATE CUSTOMER P.O. JOB NUMBER

ADDRESS CITY STATE ZIP

CONTACT MANUFACTURER MODEL NO. SERIAL NO. CUSTOMER I.D. NO.

LOCATION ACCESS CAPACITY LIFT

MOUNTING LOAD TEST MPT CNTRL VOLT. VOLTAGE PHASE

DESCRIPTION GOOD DEFECTIVE COMMENTS

COMMENTS:

Copy of Report Issued Equipment left in Service Removed from service, locked out and tagged out, owner assumed responsibility

DATE:Piquette & Howard Serviceman (Signature)

DATE:Piquette & Howard Serviceman (Print)

DATE:CUSTOMER ACCEPTANCE (Signature)

DATE:CUSTOMER (Print)

222 Plaistow RoadPlaistow, NH 03865Tel: (603) 382-3182Fax: (603) 382-3582

IR # E

SAMPLE

CHARGING BUCKET

Lifting Eye/Bale

Support Arm

Cover

Cover Handle

Cover Hinge

Cover Latch

Bottom Door Arms

Bottom Door Hinge

Outside Bottom Flange

Support BoltsBolt on Exhaust Cover

Capacity Markings

External Welds/Misc.

CUSTOMER DATE CUSTOMER P.O. JOB NUMBER

ADDRESS CITY STATE ZIP

CONTACT MANUFACTURER MODEL NO. SERIAL NO. CUSTOMER I.D. NO.

LOCATION ACCESS CAPACITY LIFT

MOUNTING LOAD TEST MPT CONTROL VOLT. VOLTAGE PHASE

DESCRIPTION GOOD DEFECTIVE COMMENTS

COMMENTS:

Copy of Report Issued Equipment left in Service Removed from service, locked out and tagged out, owner assumed responsibility

DATE:Piquette & Howard Serviceman (Signature)

DATE:Piquette & Howard Serviceman (Print)

DATE:CUSTOMER ACCEPTANCE (Signature)

DATE:CUSTOMER (Print)

59 Ames StreetLawrence, Massachusetts 01841Tel: (978) 685-6145Fax: (978) 685-7936

IR # F

SAMPLE

PNEUMATIC CHAIN HOISTCUSTOMER DATE CUSTOMER P.O. JOB NUMBER

ADDRESS CITY STATE ZIP

CONTACT MANUFACTURER MODEL NO. SERIAL NO. CUSTOMER I.D. NO.

LOCATION ACCESS CAPACITY LIFT

MOUNTING LOAD TEST MPT PNEUMATIC

DESCRIPTION GOOD DEFECTIVE COMMENTS

COMMENTS:Copy of Report Issued Equipment left in Service Removed from service, locked out and tagged out, owner assumed responsibility

DATE:Piquette & Howard Serviceman (Signature)

DATE:Piquette & Howard Serviceman (Print)

DATE:CUSTOMER ACCEPTANCE (Signature)

DATE:CUSTOMER (Print)

222 Plaistow RoadPlaistow, NH 03865Tel: (603) 382-3182Fax: (603) 382-3582

WARREN BUSINESS GRAPHICS, INC. WALTHAM, MA 02451 • (781) 647-7760

IR # G

Load ChainChain Guide/ContainerLift Wheel/Load WheelLoad Hook/BlockTop Hook/LugLatchesHoist BrakePaddle Limit/Valve BodyHoist Air MotorAir Hose/FestoonRegulator/OilerAir Shutoff/DisconnectPendant/Rope ControlGearcaseTrolley Wheels/FrameRunway/SplicesEnd Trucks/Bridge WheelsEndstopsHangers, Support StructureCapacity/Warning TagBracingJib Base/Mast/BoomHead Rollers/Stops/HingesBase/AnchorsMonorail/Hanger Supports

G Pneumatic Chain Hoist Inspection Rpt_Hand Chain Fall Insp Rpt 7/2/14 1:24 PM Page 1

SAMPLE

1-Cover-SAMPLESAMPLE REPORTAcme Company1 Boston RoadLawrence, MA 01841Crane & Hoist Inspection ReportAugust 2015

2-Table of Contents SAMPLECrane & Hoist Inspection ReportTable of Contents1. Repair quote and Inspection Reports5. D-Electric Chain Hoist Inspection Reports

3-Copy of Sample Quote4-A1 Crane Survey Auto Pour Area5-A2 Crane Survey6-A3 Crane Survey7-B Hand Chain Fall CM Cyclone8-C Elec Chain Hoist CM9-CS Chain Sling Inspection Sheet10-D Elec Cable Hoist Insp Rpt 11-E Push Pull Trolley12-F Charging Bucket 001ADPC0C0.tmpCrane & Hoist Inspection ReportTable of Contents1. Repair quote and Inspection Reports5. D-Electric Cable Hoist Inspection Reports

cn: Acme Companystreet: 1 Boston Roadjob: MA-1234cont person: John Doephone: 800-555-1212man: US Monorail/Detroitlocation: Main Engine Roomcust id: -capmh: 4 Toncapaux: -cap br: 4 Tonspan: 12'ser num br: -ser num mh: 123456ser num ah: M/N RRpow sup: 3ac volt: 460dc volt: -cont volt: 120Vlift: 12'access: Liftload test: -mpt: -ph tech: Dale Purdydate 1: 06/12/15date 2: 06/12/15comments: Repair/replaced bridge tagline complete, new flat cable festoon.c ri: Yesremoved: Offtop run bridge: Offunder: Yesgantry: Offtop run ah: Offunder ah: Yessg: Yessd: Offmg: Yesmd: Offbg: Offbhg: Offgeg: Yescog: Yesfdg: Offbrd: Offged: Offcod: Offrdd: Offmhcg: Offmhcd: Offahcg: Offahcd: Off1tcg: Off1tcd: Off2tcg: Off2tcd: Offbbpg: Offbbpd: Offglg: Offgld: Offlig: Offlid: Offsssg: Offsssd: Offmldg: Offmldd: Offmlcg: Offmlcd: Yesclg: Yescld: Offfeg: Offfed: Offb1g: Offb1d: Offtro: Offtrb: Offfcg: Yesfcd: Offftg: Yesftd: Offhag: Yeshad: Offhsg: Yeshsd: Offesg: Yesesd: Offccg: Yesccd: Offcto: Offctb: Offttg: Offttd: Offtrtlg: Offtrtld: Offtbg: Offtbd: Offb2g: Offb2d: Offcsg: Offcsd: Offrcg: Offrcd: Offrucg: Yesrucd: Offrscg: Yesrscd: Offrecg: Yesrecd: Offrpfg: Yesrpfd: Offrcsg: Yesrcsd: Offbcg: Offbcd: Offbrcg: Offbrcd: Offbscg: Offbscd: Offbecg: Offbecd: Offbpfg: Offbpfd: Offbcsg: Offbcsd: Offb3g: Offb3d: Offb4g: Offb4d: Offb5g: Offb5d: Offb6g: Offb6d: Offcag: Yescad: Offpbg: Yespbd: Offlag: Yeslad: Offpsg: Yesdcg: Yesscd: Offnbg: Yesnbd: Offpcg: Yespcd: Offcocg: Yescocd: Offoosg: Offoosd: Offsesg: Offsesd: Offbag: Offbad: Offcorg: Offcord: Offtrg: Offtrd: Offreg: Offred: Offopg: Offopd: Offb7g: Offb7d: Offb8g: Offb8d: Offb9g: Offb9d: Offb10g: Offb10d: Offb11g: Offb11d: Offb12g: Offb12d: Offb13g: Offb13d: Offb14g: Offb14d: Offb15g: Offb15d: Offb16g: Offb16d: Offb17g: Offb17d: Offc63: c64: N/Ac65: N/Ac66: N/Ac67: N/Ac68: N/Ac69: N/Ac70: Some wear.c71: c72: c73: c74: c75: c76: c77: c78: N/Ac79: c80: N/Ac81: N/Ac82: N/Ac83: c84: All new.c85: c86: New.c87: New.c88: N/Ac89: New.c90: N/Ac91: c92: c93: c94: very shallow.c95: Should have on hoist, bridge panelc96: N/Ac97: N/Ac98: N/Ac99: N/Ac100: N/Ac101: N/Ac102: N/Ac103: N/Ac104: N/Ac105: N/Ac106: alg: Yesald: Offgig: Yesgid: Offrag: Offrad: Offwlg: Offwld: Offetg: Yesetd: Offdwg: Yesdwd: Offiwg: Yesiwd: Offrsg: Yesrsd: Offbug: Offbud: Offacg: Yesacd: Offshg: Yesshd: Offapg: Yesapd: Offkkg: Yeskkd: Offbgbg: Yesbgbd: Offbrag: Offbrad: Offmog: Yesmod: Offsrg: Offsrd: Offbrug: Offbrud: Offbrhg: Offbrhd: Offssg: Offssd: Offfrdg: Offfrdd: Offmcg: Yesmcd: Offctg: Yesctd: Offrung: Yesrund: Offjbog: Offjbod: Offligg: Offligd: Offhbg: Offhbd: Offloug: Yeslud: Offcamg: Yescamd: Offb1: Offb2: Offb3: Offb4: Offb5: Offb6: Offb7: Offb8: Offb9: Offb10: Offb11: Offb12: Offb13: Offb14: Offb15: Offb16: Offb17: Offb18: Offb19: Offb20: Offb21: Offb22: Offb23: Offb24: Offb25: Offb26: Offb27: Offb28: Offb29: Offb30: Offb31: Offb32: Offmg1: Yesmg2: Yesmg3: Yesmg4: Yesmg5: Yesmg6: Yesmg7: Offmg8: Yesmg9: Yesmg10: Yesmg11: Yesmg12: Offmg13: Offmg14: Offmg15: Offmg16: Offmg17: Yesmg18: Yesmg19: Yesmg20: Yesmg21: Offmg22: Yesmg23: Yesmg24: Yesmg25: Yesmg26: Offmg27: Offmg29: Offmg30: Offmg31: Offmg32: Offmg33: Offmg34: Offmg35: Offmg36: Offmg37: Offmg38: Offmg39: Offmg40: Offmg41: Offmg42: Offmg43: Offmg44: Offmg45: Offmg46: Offmg47: Offmd1: Offmd2: Offmd3: Offmd4: Offmd5: Offmd6: Offmd7: Offag1: Offag2: Offag3: Offag4: Offag5: Offag6: Offag7: Offad1: Offad2: Offad3: Offad4: Offad5: Offad6: Offad7: Offad8: Offad9: Offad10: Offad11: Offad12: Offad13: Offad14: Offad15: Offag8: Offag9: Offag10: Offag11: Offag12: Offag13: Offag14: Offag15: Offmd8: Offmd9: Offmd10: Offmd11: Offmd12: Offmd13: Offmd14: Offmd15: Offmd16: Offmd17: Offmd18: Offmd19: Offmd20: Offmd21: Offmd22: Offmd23: Offag16: Offag17: Offag18: Offag19: Offag20: Offag21: Offag22: Offag23: Offad16: Offad17: Offad18: Offad19: Offad20: Offad21: Offad22: Offad23: Offmd24: Offmd25: Offmd26: Offmd27: Offmd29: Offmd30: Offmd31: Offmd32: Offag24: Offag25: Offag26: Offag27: Offag29: Offag30: Offag3`1: Offag32: Offad24: Offad25: Offad26: Offad27: Offad29: Offad30: Offad31: Offad32: Offmd33: Offmd34: Offmd35: Offmd36: Offmd37: Offmd38: Offmd39: Offmd40: Offag33: Offag34: Offag35: Offag36: Offag37: Offag38: Offag39: Offag40: Offad33: Offad34: Offad35: Offad36: Offad37: Offad38: Offad39: Offad40: Offmd41: Offmd42: Offmd43: Offmd44: Offmd45: Offmd46: Offmd47: Offag41: Offag42: Offag43: Offag44: Offag45: Offag46: Offag47: Offad41: Offad42: Offad43: Offad44: Offad45: Offad46: Offad47: Offc1: c2: c3: c4: c5: c6: c7: N/Ac8: N/Ac9: N/Ac10: N/Ac11: c12: c13: N/Ac14: N/Ac15: c16: c17: c18: c19: c20: c21: c22: 6 c23: c24: c25: N/A c26: N/Ac27: N/Ac28: N/Ac29: N/Ac30: N/Ac31: N/Ac32: N/Ac33: N/Ac34: c35: c36: c37: c38: c39: c40: c41: c42: c43: c44: c45: c46: c47: c48: c49: c50: c51: c52: c53: c54: c55: c56: c57: c58: c59: c60: c61: c62: s1: s2: s3: s4: s5: s6: s7: N/As8: s9: s10: s11: s12: N/As13: N/As14: N/As15: N/As16: N/As17: s18: s19: s20: s21: N/As22: s23: s24: Small minor leaks.s25: s26: s27: s28: s29: s30: s31: s32: s33: s34: s35: s36: s37: s38: s39: s40: s41: s42: s43: s44: s45: s46: s47: s48: s49: s50: s51: s52: s53: s54: s55: s56: s57: s58: s59: s60: s61: s62: s63: s64: s65: s66: s67: A: 0677bd: Offpsd: OffDATE6: 06/12/15cust: Acme Companydate: 06/12/2015po: 425669jobno: MA-1234add: 1 Boston Roadcity: Lawrencestate: MAzip: 01841contact: LawrenceMODNO: ShopstarCUSTID: -LOADTEST: -MPT: -CNTRVT: 120PHASE: 1phsig: Signature on Filephprint: Dale Purdydate2: 06/12/15date3: 06/12/15custsig: Signature on Filecust print: John Doedate4: 06/12/15date5: 06/12/15commments: g1: Yesg2: Yesg3: Yesg4: Offg5: Yesg6: Yesg7: Yesg8: Yesg9: Offg10: Offg11: Yesg12: Offg13: Yesg14: Yesd1: Offd2: Offd3: Offd4: Offd5: Offd6: Offd7: Offd8: Offd9: Offd10: Offd11: Offd12: Offd13: Offd14: Offd15: Offd16: Offd17: Offd18: Offd19: Offd20: Offd21: Offd22: Offd23: Offd24: Offd25: Offd26: Offd27: Offd28: Offg15: Yesg16: Yesg17: Yesg18: Offg19: Yesg20: Offg21: Yesg22: Yesg23: Yesg24: Offg25: Offg26: Offg27: Offg28: Yesd29: Offd30: Yesd31: Offd32: Offg29: Yesg30: Offg31: Yesg32: Offrem: Offequip: Yescopy: Yesir: 0677CSNO: 0502NAME: Acme CompanyCONTACT: John DoeSURVEY: Dale PurdyDATE: 06/12/2015JOB: MA-1234L1: Production FloorM1: L3S1: R1-CSC-1T1: EE1 with sling hookSI1: 3/16 SS cableR1: 44"C1: Rusting slightly, lubed.L2: Production FloorM2: L3S2: R1-CSC-2T2: EE1 with sling hookSI2: 3/16 SS cableR2: 44"L3: Production FloorM3: L3S3: R1-CSC-3T3: EE1 with sling hookSI3: 3/16 SS cableR3: 44"L4: Production FloorM4: L3S4: R1-CSC-4T4: EE1 with sling hookSI4: 3/16 SS cableR4: 44"L5: Production FloorM5: Lift AllS5: 169563-AT5: EE1601SI5: 1"R5: 3' NylonL6: Production FloorM6: Lift AllS6: 169563-BT6: EE1601SI6: 1"R6: 3' NylonL7: Production FloorM7: Maxzzella Lifting Tech.S7: MS00373080T7: EN1901SI7: 1"R7: 6' Endless NylonL8: ShippingM8: Lift AllS8: 1492056T8: MEN1-602DSI8: 2"R8: 2' PolyesterL9: ShippingM9: CMS9: 5J1535T9: DG ChainSI9: 9/32"R9: 10'SERVICE: Signature on File - Dale PurdyCUST SIG: Signature on FileCUSTPRINT: John DoeO1: YesO2: YesO3: Yes04: YesO5: YesO6: YesO7: YesO8: YesO9: YesF1: OffH1: OffP1: OffF2: OffF3: OffF4: OffF5: OffF6: OffF7: OffF8: OffF9: OffH2: OffH3: OffH4: OffH5: OffH6: OffH7: OffH8: OffH9: OffP2: OffP3: OffP4: OffP5: OffP6: OffP7: OffP8: OffP9: OffIR: 1036CUST: Acme CompanyDATE1: 06/12/15PO: 425669JOBNO: MA-1234ADD: 1 Boston RoadCITY: Lawrence, MA 01841STATE: MAZIP: 01841CON: John DoeMAN: CM MONO: 44269310SERNO: 123456CUTNO: -LOC: Metal Market MachineACC: Machine PlatformCAP: 300#LIFT: 10'MOUNT: Hook/Shackle/Lug on Fixed JibLT: -CNVT: 120VOLT: 120PH: 3C2: Items 1-4 should have had a d-ring for all 4 rope slings, missing all thimbles.C3: Items 1-4 should have had a d-ring for all 4 rope slings, missing all thimbles.C4: Items 1-4 should have had a d-ring for all 4 rope slings, missing all thimbles.C5: C6: C7: C8: Inspected sling only, not attachment.C9: C10: C11: C12: Impulse G+ series 4.C13: N/AC14: C15: C16: Tandem side entry, TC.C17: Should replace wiring w/resistor wire (high temp).C18: C19: New case/cover melted bad (order 2).C20: Enrange, newer 6pb transmitter, some burn marks.C21: C22: C23: Impulse VFD.C24: C25: Greased all.C26: C27: Same, see note 1.C28: Limit for left direction malfuntion, drive keeps trying to close.C29: C30: Need to order enrange transmitter warning tags (6).COMMENTS: Hoist is used in hot environment, over ovens and ladle heating, shut down work/repair only, cable bad, need some spare parts...quote asap.PHSIG: Signature on FileDATE4: 06/12/15PHPR: Dale PurdyDATE5: 06/12/15CUSTSIG: Signature on FileDATE 2: 06/12/15CUSTPR: John DoeDATE3: 06/12/15R: YesE: YesS: OffG1: OffG2: OffG3: OffG4: OffG5: OffG6: OffG7: OffG8: OffG9: OffG10: YesG11: YesG12: YesG13: OffG14: YesG15: YesG16: YesG17: OffG18: YesG19: OffG20: YesG21: YesG22: YesG23: YesG24: YesG25: YesG26: YesG27: YesG28: YesG29: YesG30: YesD1: YesD2: OffD3: OffD4: OffD5: OffD6: OffD7: OffD8: OffD9: OffD10: OffD11: OffD12: OffD13: OffD14: OffD15: OffD16: OffD17: YesD18: OffD19: YesD20: OffD21: OffD22: OffD23: OffD24: OffD25: OffD26: OffD27: OffD28: OffD29: OffD30: OffCustomer: Acme CompanyDate: 06/12/15CustomerPO: 425669Job Number: MA-1234Address: 1 Boston RoadCity: LawrenceState: MAZip: 01841Contact: John DoeManufacturer: CMModel No: -Serial No: K1574Customer ID No: -Location: Maintenance Access: 8' StepCapacity: 1 TonLift: 10'Mounting: Lug Mount / PP Trolley/GantryLoad Test: -Voltage: -Phase: -Control Volt: -Comments: Customer Print: John DoeDate1: 06/12/15hw: Yeshwc: Yeshwcd: Offhwd: Offhc: Yeshcd: Offr: Yesrd: Offbdd: Offp: Yespd: Offps: Yesds: Yesdsd: Offgc: Yesgcd: Offg: Yesgd: Offlw: Yeslwd: Offlc: Yeslcd: Offcg: Yescgd: Offdes: Yesdesd: Offlww: Offlwwd: Offlh: Offlhd: Offthsl: Offthsld: Offl: Offld: Offt: Offtd: Offtl: Offtld: Offcm: Offcmd: Offcri: Yesels: Yesrs: Offphs: Dale Purdydate6: 06/12/15title: PUSH PULL TROLLEY - MONORAILB1: Trolley Side PlatesB2: Trolley WheelsB3: Trolley GaugeB4: Trolley LugsB5: Swivel AssemblyB6: Bearings/ShaftsB7: Sprocket B21: AlignmentB8: Load Hooks/Rack AssemblyB9: CapacityB10: MonorailB11: Hangers & SupportsB12: SwitchesB13: EndstopsB14: B15: B16: B17: B18: B19: B20: 4: 4256695: MA-12346: 1 Boston Road7: Lawrence8: MA9: 0184110: John Doe11: -12: -13: 123414: 00115: -16: -17: 2000 lbs.18: -19: -20: -21: Okay22: -23: -24: -25: Yes27: Off28: Yes29: Off30: Off31: Yes32: Yes33: Off34: Yes35: Off36: Yes37: Off38: Yes39: Off40: Off41: Yes42: Yes43: Off44: Yes45: Off46: Yes47: Off48: Yes49: Off50: Yes51: Off52: 53: 54: Cracked welds under suction hood adaptor, lid and hoodmount.55: 56: 57: 58: 59: Poor welds with cracks.60: 61: 62: 63: 64: 65: 66: 67: 68: 69: 70: 71: 72: 73: 74: 76: Signature on File77: Dale Purdy78: 06/12/1579: 06/12/1580: Signature on File81: John Doe82: 06/12/1583: 06/12/1585: Yes84: Yes86: OffIR#: 1155PNEUMATIC CHAIN HOISTRow1: Acme CompanyPNEUMATIC CHAIN HOISTRow1_2: 06/12/15PNEUMATIC CHAIN HOISTRow1_3: 425669PNEUMATIC CHAIN HOISTRow1_4: MA-1234Text4: 0: 1 Boston Road1: 0: Lawrence1: 0: MA1: 01841

Text5: John DoeText6: CM Text7: ShopairText8: 123456Text9: -Text10: Small Fab., East WallText11: Fl.Text12: 300#Text13: 10'Text14: HookText15: -Text16: -Text17: 90psi.Check Box1: 0: 0: Yes1: Off

1: 0: Yes1: Off

2: 0: Yes1: Off

3: 0: Yes1: Off

4: 0: Yes1: Off

5: 0: Yes1: Off

COMMENTSRow1: Some wear.COMMENTSRow2: COMMENTSRow3: COMMENTSRow4: COMMENTSRow5: COMMENTSRow6: Check Box20: 0: 0: Yes1: Off

1: 0: Yes1: Off

2: 0: Yes1: Off

3: 0: Yes1: Off

4: 0: Off1: Off

5: 0: Off1: Off

6: 0: Yes1: Off

COMMENTSRow7: COMMENTSRow8: COMMENTSRow9: COMMENTSRow10: COMMENTSRow11: N/ACOMMENTSRow12: N/ACOMMENTSRow13: Pendant.Check Box21: 0: 0: Yes1: Off

1: 0: Off1: Off

2: 0: Off1: Off

3: 0: Off1: Off

4: 0: Off1: Off

5: 0: Off1: Off

6: 0: Yes1: Off

COMMENTSRow14: COMMENTSRow15: N/ACOMMENTSRow16: N/ACOMMENTSRow17: N/ACOMMENTSRow18: N/ACOMMENTSRow19: N/ACOMMENTSRow20: Check Box22: 0: 0: Off1: Off

1: 0: Off1: Off

2: 0: Off1: Off

3: 0: Off1: Off

4: 0: Off1: Off

5: 0: Off1: Off

6: 0: Off1: Off

COMMENTSRow21: N/ACOMMENTSRow22: N/ACOMMENTSRow23: N/ACOMMENTSRow24: N/ACOMMENTSRow25: N/AText3: 0: 1: 2: 3:

COMMENTSRow26: COMMENTSRow27: Check Box23: 0: 0: Off1: Off

1: 0: Off1: Off

COMMENTSRow28: COMMENTSRow29: Copy of Report Issued: OnEquipment left in Service: OnRemoved from service locked out and tagged out owner assumed responsibility: Offundefined: Visual only, hoist hung on wall/column - in storage, not in use.1: 2: Acme Company3: 06/12/15undefined_2: Signature on Filefill_129: 06/12/15undefined_3: Signature on FileText1: 06/12/15undefined_4: Dale Purdyfill_130: 06/12/15undefined_5: John DoeText2: 06/12/15