PALLET JACK INSPECTION & TEST REPORT

CUSTOMER DETAILS

CUSTOMER

Date

ADDRESS

ORDER NO

CONTACT

TEL NO:

DESCRIPTION OF UNIT

UNIT:

SERIAL NO:

WLL:

LENGTH/SIZE/REACH

PLANT

LOCATION:

PREVIOUS INSPECTION DATE *

NEXT INSPECTION DATE *

EQUIPMENT CONDITION

DATE PLATE / ID/MARKINGSGOODFAIRBAD

Remarks

STEER HANDLEGOODFAIRBAD

Remarks

RELEASE LEVER/ TRIGGERGOODFAIRBAD

Remarks

RELEASE CHAIN/MECHANISMGOODFAIRBAD

Remarks

TOW BARGOODFAIRBAD

Remarks

PISTON PUMP & SPRINGSGOODFAIRBAD

Remarks

PUMP UNITGOODFAIRBAD

Remarks

RELEASE VALVE LAVERGOODFAIRBAD

Remarks

WHEELLOCKSGOODFAIRBAD

Remarks

TORSION TUIBEGOODFAIRBAD

Remarks

PUSH RODGOODFAIRBAD

Remarks

A FRAMNE/ STRUCTUREGOODFAIRBAD

Remarks

MUSTGOODFAIRBAD

Remarks

MUST ROLLERGOODFAIRBAD

Remarks

CHAINGOODFAIRBAD

Remarks

LOAD WHEELSGOODFAIRBAD

Remarks

FORKS/ ATTACHMENTGOODFAIRBAD

Remarks

NOTES

NOTES:

Visual InspectionYESNO

RESULTS

RESULTSPASSFAIL

INSPECTOR NAME & SURNAME

POSITION/ TITLE;

CERTIFIED BY

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CUSTOMER REPRESENTATIVE:

CUSTOMER REPRESENTATIVE

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Consent *

THE CUSTOMER ACKNOLEDGES THAT DEFECTIVE EQUIPMENT WILL NOT BE USED UNTIL REPAIRS ARE DONE AND THE UNIT IS INSPECTED AND/OR TESTED

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This Is To Certify That The Below Mentioned
Lifting tackle has been Examined/Inspected And/Or Tested Accordance With SANS 509:2007 And Meets Safety Standards In Accordance With The OHS Act And The MHS Act.