Annual Periodic Vehicle Inspection Report
Name and Adrress of Inspecting Company or Agency
_______________________________________________________________________________
Registered Owners Name | Date | Time
| |
________________________________________________________|__________|___________
Street |Certified Inspector's Name (Print)
|
__________________________________________|____________________________________
City, State, Zip Code |The signing of this inspection report
|certifies that the technician meets
__________________________________________|and exceeds all requirements of
Motor Carrier Operating Vehicle |49 CFR 396.17 and compatible state
(if different from the Owner) |regulations and that the technician
|has the necessary tools, and is
_________________________________________ |skilled in completion of the annual
Street |inspection,as listed in 49 CFR 396.17
|
_________________________________________ |Technicians Signature:
City, State, Zip Code |
_________________________________________ |_____________________________________
License Plate Number/State |Vehicle Identification Number |Vehicle Make
| |
__________________________ |_____________________________ |_____________________
Vehicle Model |Model Year |
| |
___________________________|______________|_____________________________________
Vehicle Components Inspected
________________________________________________________________________________
Mark Columns as Follows: X=OK; O=Needs Repair; N/A=Does not Apply; Fill in
Repair Date
________________________________________________________________________________
________________________________________________________________________________
OK |Need |Repair | |OK |Need |Repair |
|Repair|Date |ITEM | |Repair|Date |ITEM
___|______|________|____________________|___|______|________|___________________
| | |1.BRAKE SYSTEM | | | |5.FUEL SYSTEMS
___|______|________|____________________|___|______|________|___________________
| | |Adjustment | | | |Visible Leaks
___|______|________|____________________|___|______|________|___________________
| | |Drums or Rotors | | | |Fill Caps in place/
| | | | | | |Intact
___|______|________|____________________|___|______|________|___________________
| | |Hoses and or Tubing | | | |Tank(s) securely
| | | | | | |Attached
___|______|________|____________________|===|======|========|===================
| | |Lining | | | |6.LIGHTING DEVICES
___|______|________|____________________|___|______|________|___________________
| | |Warning-Low Pressure| | | |Headlamps
___|______|________|____________________|___|______|________|___________________
| | |Tractor Protection | | | |Front Turn Signals
| | |Valve | | | |
___|______|________|____________________|___|______|________|___________________
| | |Air Compressor | | | |Front ID/ Clearance
| | | | | | |Lamps
___|______|________|____________________|___|______|________|___________________
| | |Service Brakes | | | |Side Marker Lamps
| | | | | | |Left
___|______|________|____________________|___|______|________|___________________
| | |Parking Brakes | | | |Side Marker Lamps
| | | | | | |Right
___|______|________|____________________|___|______|________|___________________
| | |Electric Brakes | | | |Rear Turn Signals
___|______|________|____________________|___|______|________|___________________
| | |Hydraulic Brakes | | | |Stop Lamps
___|______|________|____________________|___|______|________|___________________
| | |Vacuum Brakes | | | |Tail Lamps
___|______|________|____________________|___|______|________|___________________
| | |Warning (System | | | |Rear ID/Clearance
| | |Failure) | | | |Lamps
===|======|========|====================|___|______|________|___________________
| | |2.STEERING SYSTEM | | | |Reflectors/Ref Tape
___|______|________|____________________|===|======|========|===================
| | |Free Play (Lash) | | | |7.Coupling Devices
___|______|________|____________________|___|______|________|___________________
| | |Steering Column | | | |5TH Wheel
___|______|________|____________________|___|______|________|___________________
| | |Front Axle Beam | | | |Pintle Hooks
___|______|________|____________________|___|______|________|___________________
| | |Steering Gear Box | | | |Drawbar Eye
___|______|________|____________________|___|______|________|___________________
| | |Pitman Arm | | | |Drawbar Tongue
___|______|________|____________________|___|______|________|___________________
| | |Ball & Socket Joints| | | |Safety Devices
___|______|________|____________________|===|======|========|===================
| | |Tie Rods&Drag Links | | | |8.EXHAUST SYSTEM
___|______|________|____________________|___|______|________|___________________
| | |Nuts, Bolts,Fastners| | | |Leaks
___|______|________|____________________|___|______|________|___________________
| | |Power Steering Fluid| | | |Placement
===|======|========|====================|===|======|========|===================
| | |3.WINDSHEILDS | | | |9.SAFE LOADING
===|======|========|====================|___|______|________|___________________
| | |4.WIPERS | | | |Securement Devices
===|======|========|====================|===|======|========|===================
OK |Need |Repair | |OK |Need |Repair |
|Repair|Date |ITEM | |Repair|Date |ITEM
___|______|________|____________________|___|______|________|___________________
| | |10.SUSPENSION | | | |List any other
___|______|________|____________________| | | |condition which may
| | |Springs(Cracked, | | | |affect safe vehicle
| | |Broken/Shifted) | | | |operation
___|______|________|____________________|___|______|________|___________________
| | |U Bolts Hangers,Etc | | | |
___|______|________|____________________|___|______|________|___________________
| | |Torque, Radius, | | | |
| | |Tracking Arms | | | |
===|======|========|====================|___|______|________|___________________
| | |11.FRAME | | | |
___|______|________|____________________|___|______|________|___________________
| | |Frame Members | | | |
___|______|________|____________________|___|______|________|___________________
| | |Tire & Wheel | | | |
| | |Clearance | | | |
___|______|________|____________________|___|______|________|___________________
| | |Sliding Subframe | | | |
| | |(adj.axle) | | | |
===|======|========|====================|___|______|________|___________________
| | |12.TIRES | | | |
___|______|________|____________________|___|______|________|___________________
| | |Steering Axle Tires | | | |
| | |Condition | | | |
___|______|________|____________________|___|______|________|___________________
| | |Steering Tires | | | |
| | |Over 4/23" Tread | | | |
___|______|________|____________________|___|______|________|___________________
| | |Other Tires | | | |
| | |Condition | | | |
___|______|________|____________________|___|______|________|___________________
| | |Other Tires | | | |
| | |Over 4/23" Tread | | | |
===|======|========|====================|___|______|________|___________________
| | |Warning (System | | | |
| | |Failure) | | | |
===|======|========|====================|___|______|________|___________________
| | |13.WHEELS & RIMS | | | |
___|______|________|____________________|___|______|________|___________________
| | |Lock/Slide Ring | | | |
___|______|________|____________________|___|______|________|___________________
| | |Fasteners | | | |
___|______|________|____________________|___|______|________|___________________
| | |Disk/Spoke Condition| | | |
___|______|________|____________________|___|______|________|___________________
| | |Welds | | | |
===|======|========|====================|===|======|========|===================
I CERTIFY THE ANNUAL VEHICLE INSPECTION HAS BEEN DONE ACCURATELY AND COMPLETELY.
I FURTHER CERTIFY THAT THIS INSPECTION COMPLIES WITH THE REQUIREMENTS OF
49 CFR 396.21.
This information must be on board the vehicle, either as a copy of this report,or
on a decal that complies with 49 CFR 396.17(c)(2). this report must be kept a
minimum of fourteen months from the date of completion.
Certified Inspector Signature:________________________________ Date:____________
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Inspectors Qualifications
Certification - 49 CFR 396.19
Motor carriers are responsible for insuring that individual(s) performing an
annual inspection under 49 CFR 396.17 are qualified as follows:
> Understands the inspection criteria set forth in Part 393 and
Appendix G and can identify defective components
> Is knowledgeable of and has mastered the methods, procedures, tools
and equipment used when performing an inspection
> Is capable of performing an inspection by reason of experience,
training, or both, and qualifies in one of the following catgories
(check all that apply):
I. ___ Successfully completed a State or Federal training program or has a
certificate from a State or Canadian Province which qualifies the
person to perform commercial vehicle safety inspections.
Specify:______________________________________________________________
II. ___ Have a combination of training or experience totaling at least one
year as follows (Check all that apply):
a. ___ Participation in a truck manufacturer-sponsored training
program or similar commercial training program designed to
train students in truck operation and maintenance.
When and Date:______________________________________________________
b. ___ (years) experience as a mechanic or inspector in a motor
carrier maintenance program.
Name and Date:______________________________________________________
c. ___ (years) experience as a mechanic or inspector in truck
maintenance at a commercial garage, fleet leasing company
or similar facility.
Name of Facility and Date:__________________________________________
d. ___ (years) experience as a commercial vehicle inspector for a
State, Provincial, or Federal Government.
When and Date:______________________________________________________
I certify the above information is true and accurate to the best of my knowledge
Employee:____________________________________________ Date:_______________
Signature of Mechanic/Inspector
Motor Carrier:_______________________________________ Date:_______________
Signature of Employer/Supervisor
Evidence of Inspector Qualification is on file at:
____________________________________________________________________________
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Brake Inspectors Qualifications
Certification - 49 CFR 396.25
"Brake Inspector" means any employee of a motor carrier who is responsible for
ensuring all brake inspections, maintenance, service, or repairs to any
commercial motor vehicle, subject to the motor carrier's control, meet the
applicable Federal standards.
No motor carrier shall require or permit any employee who does not meet minimum
brake inspector qualifications to be responsible for the inspection, maintenance,
service or repairs of any brakes on its commercial motor vehicles.
Minimum Qualifications:
> Understands and can perform brake service and inspection
> Is knowledgeable of and has mastered the methods, procedures, tools
and equipment necessary to perform brake service an inspection
> Is capable of performing brake service or inspection by reason of
experience, training, or both, and qualifies in one of the following
categories (check all that apply):
I. ___ Has successfully completed an apprenticeship program sponsored or
approved by a State, Canadian Province, a Federal agency or labor
union, or has a certificate from a State or Canadian Province
which qualifies the person to perform brake service or inspection.
Specify:______________________________________________________________
II. ___ Has brake related training or experience or a combination of both
thereof totaling at least one year as follows(Check all that apply):
a. ___ Participation in a brake maintenance or inspection training
program sponsored by a brake or vehicle manufacturer or
similar commercial training program.
When and Date:______________________________________________________
b. ___ (years) experience performing brake maintenance or inspection
in a motor carrier maintenance program.
Name and Date:______________________________________________________
c. ___ (years) experience performing brake maintenance or inspection
at a commercial garage, fleet leasing company or similar
facility.
Name of Facility and Date:__________________________________________
I certify the above information is true and accurate to the best of my knowledge
Employee:____________________________________________ Date:_______________
Signature of Mechanic/Inspector
Motor Carrier:_______________________________________ Date:_______________
Signature of Employer/Supervisor
Evidence of Inspector Qualification is on file at:
____________________________________________________________________________
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
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