ELEVATOR REPORT OF INSPECTION

Date Inspected

Next Inspection Due Date

Certificate posted?

Elevator #

Location (building name)

Street Address, City, Zip

Owner Name, Street Address, City, State, Zip or P.O. Box

Phone- local

Lessee/Management firm

Street Address, City, Zip, County

Maintenance Contract?

If yes, company name and branch

Type of Inspection

Type of Unit

If Other, specify

Elevator Status

Type of machine

If Other, specify

Speed

Capacity

# of openings on car

# of Floors

Door Width

Door Torque

Door Close Sp.

Type Door

Due Date 5 Yr. Safety Test

Violations

I hereby certify this is a true report of my inspection.

Clear Signature

Inspector ID#

Date

Clear Signature