Facility/General Information / Building Name: / Manufacturer: / Capacity:
Address: / State Reg #: / Job/Contract #:
City: / Install Date: / Duty: / Passenger Freight
Zip: / Rated Speed: / Freight Loading Class: / C1 C2 C3
Circle One / 1 Acceptance / Category 1 Tests / 2Category 1 and 5 Witnessed Testing
Date Tests Performed: / Was Inspector Present: / Yes No / If "Yes" Inspector Must Sign Test Report
Relief Valve / Piston Diameter: / in / Relief Valve to be set at 150% or less of the Working Pressure / Adjustment Needed: / Yes No
No Load Working PSI: / psi / Adjustments Sealed: / Yes No
1Full Load Working PSI: / psi / Relief Valve Setting: / psi / Test Tag Installed: / Yes No
2 Plunger Gripper Operational: / NA Yes No / 2 Overspeed Valve operational: / NA Yes No
Power Down Static Test / Time Started: / Proper Fuses Installed: / Yes No / Connections Tight: / Yes No
Time Ended: / Controller Clean: / Yes No / Jumpers Removed: / Yes No
Elapsed Time: / Relay(s) Visually Inspected: / Yes No
Change In Car Position: / Yes No / If "yes" Distance in / Oil Loss Accounted For: / Yes No
NOTE: If any oil loss can not be accounted for, the elevator must be removed from service and the Authority Having Jurisdiction must be notified.
Safety Devices / Stop Switches: / In Car: / Pass Fail / Pit: / Pass Fail / Top Of Car: / Pass Fail
Directional Limits: / Up: / Pass Fail / Down: / Pass Fail / Low Oil Protection: / NA Pass Fail
Final Limits: / Up: / Pass Fail / Down: / Pass Fail / Escape Hatch Contact: / NA Pass Fail
Low Oil Pressure Switch: / NA Pass Fail / Car Door Restrictor: / NA Pass Fail
Doors / Closing Force (Max 30lbf): / lbf / Safety Edge: / Pass Fail / Door Guides Secure: / Pass Fail
Closing Time: / sec / Electronic Edge: / Pass Fail / Door Interlocks/Gate Switch: / Pass Fail
Emergency Operation / Phase I Recall: / NA Pass Fail / Phase I Fire Service Instruction Signage In Place: / Yes No
Phase II Operation: / NA Pass Fail / Phase II Fire Service Instruction Signage In Place: / Yes No
Emergency Communication: / NA Pass Fail / Alarm Bell: / Pass Fail / Emergency Lights: / Pass Fail
Standby or Emergency Power Operation: / NA Pass Fail
Logs / Logs Properly Maintained: / Yes No / Logs Updated with this Annual safety test: / Yes No
Fire service logs maintained: / Yes No
Signatures / I certify all statements are true to the best of my knowledge and that all testing was performed according to The Elevator and Escalator Certification Act CRS § 9-5.5, Conveyance Regulations 7 CCR 1101-8 and adopted Codes.
Mechanic Name: / Company Name:
Signature: / Date: / State License #:
Inspector Name: / Company Name:
Signature: / Date: / State License #:
1 Required to be performed during acceptance inspections
2 Required to be performed during acceptance and Category 1 and 5 witnessed inspections
1