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DEPARTMENT OF HOMELAND SECURITY

REPORT OF TESTS FOR REGULATED LIFTING DEVICES DIVISION OF FIRE AND BUILDING SAFETY
DIVISION OF ELEVATOR AND AMUSEMENT SAFETY
State Form 34599 (R11 / 7-19) 302 West Washington Street, Room E241
Indianapolis, Indiana 46204
Telephone: (317) 232-2670
Fax: (317) 232-6609
E-mail: [email protected]
INSTRUCTIONS: File this form with the Division of Elevator Safety within fifteen (15) days after completion of test. Website: www.in.gov/dhs/2625.htm

State number
All tests are performed as per the applicable code of the regulated lifting device and not limited to the items recorded on this form.

Name of user Location of user City and State ZIP code

Date test conducted (month, day, year) Name of contractor Contractor number

Name of inspector Inspector license number Qualified elevator inspector (QEI) number

Name of mechanic Mechanic license number Signature of mechanic Date signed (month, day, year)

Capacity Rated speed Date installed (month, day, year) Code edition Type of permit
Acceptance Alteration Construction Temporary Permit
Category Manufacturer of device
Category1 / Annual Category 5 / Five year Category 3 A 10.4 Periodic
Type of device
Passenger Moving Walkway Dumbwaiter Special Purpose Personnel Elevator Stairway Lift Construction Vertical Platform Lift
Escalator Machine Roomless Freight Limited Use Limited Access Personnel Hoist Belt Manlift Inclined Chair Lift Inclined Platform Lift
Driving machine Controls
Hydraulic Traction Roped hydraulic Drum Screw Rack & Pinion Other ____________________
Type of buffer Buffer stroke Materials of rails Type of governor
Oil Spring Reduced Stroke Solid N/A Steel Wood Flyball Centrifugal N/A Other __________________
Type of safety device Standby emergency power Sprinklers Date of flex hose (month, day, year)
A B C N/A Other _________________ Yes No Yes No Shunt trip
Pit Machine room Hoistway Shut-off valve Cylinder monitor check

Bottom runby Bottom refuge Top runby Top refuge Nearest strike

I am an individual who is licensed as an elevator inspector by the State of Indiana under IC 22-15-5-11; I hereby attest under penalty that:
1. all of the above-referenced required tests have been completed by persons qualified to perform such services; and
2. the above-referenced regulated lifting device conforms to all applicable building, electrical, and equipment codes in effect at the time of installation or each alteration.

Signature Date signed (month, day, year)

Printed name Certification number Date of expiration (month, day, year)

 ASME A17.1 A - Acceptance Inspection (plus 1's, 3's, and 5's)
1 - Required for Category 1 / Annual Tests

Dumbwaiter Cart Lift

Belt Manlift A90.1

VPL ICL IPL A18.1
Hoist A10.4
LULA Electric

Escalator Moving Walkway

Electric

Hydraulic

Roped Hydraulic

Hydraulic

SPPE LULA Roped Hydraulic

Construction
3 - Required for Category 3 Tests (plus 1's)
5 - Required for Category 5 Test (plus 1's and 3's)
P - Required for A10.4 Periodic Test
X Indicate unit type and Test being reported.

ALL REQUIRED TESTS SHALL BE PERFORMED PER ADOPTED CODE.

ALL RESULTS MAY NOT BE REQUIRED TO BE RECORDED.

SPPE

SPPE

PLEASE SUBMIT ALL FAILED SAFETY TESTS.

1 1 1 Firefighters Phase I And Phase II / Instructions Posted

1 1 1 A Initiating Devices H.W. / M.R. FL Each Floor
1 1/5 1/5 1 1 1 1 Emergency Power Auxiliary Battery Lowering
1 1 All E/E/Pes Elec Prot Devices
1 1 1 1 1 1 1 Emergency Lighting
1 1 1 1 1 1 A 1 Two Way communication / Alarm
1 1 1 1 1 1 1 1 Door Closing Force
5 A 5 A 5 5 1 A A 1 1 No Load Speed Up
5 A 5 A 5 5 1 A A 1 1 No Load Speed Down
5 A 5 A 5 5 5 A A 1 Rated Speed Up
5 A 5 A 5 5 5 A A/P A 1 Rated Speed Down
1 1 1 1 1 1 1 A 1 A/P 1 1 Stop Switches
1 1 1 1 1 1 1 A A/P 1 1 Normal And Final Terminal Stopping Devices
1 1 1 1 1 1 1 A A/P Terminal Speed Reducing Device / Slowdown
5 1 1 1 1 1 A Emergency Terminal speed / Stopping
1 1 1 1 1 A A/P 1 Slack Rope Devices
1 Obstruction Devices
1 1 1 1 1 1 A 1 A/P 1 Broken Rope, Tape, Chain Devices
5 5 5 A 1 A 5 1 Braking System Rated 125 Torque
5 5 1 1 1 A Safeties Slide
A A A Unintended Down Motion Test
1 1 A Unintended Up Motion Test
1 A A Ascending Car Overspeed Test
1 1 1 1 1 A A/P 1/5 Safety Test NL Rated Load
5 5 A 125% Emergency Stop
1 5 1 A Slip Traction Stall Mach Down Direction
1 1 5 A Oil Buffer Return Time / Car - RL CWT - NL
A A A A A A A A Working Pressure
1 1 1 1 1 A 1 Relief Pressure On Stop Ring
1 1 1 1 1 A 1 Fifteen (15) Minute Static Load Test
1 1 1 1 1 A 1 Pressure Switch / Low Oil Protection
1 1 1 1 1 A Flexible Hose And Fittings
5 5 5 5 5 A 1 Down Overspeed Valve / Plunger Gripper RL
3 3 3 3 3 3 Unexposed Pistons / Pressure Vessels
5 5 1 1 5 A A/P 5 Overspeed Switch
5 5 1 1 5 A A/P 5 Trip Speed
1 1 1 1 5 A 1 A/P 1 Governor
5 5 5 5 5 A A/P 5 Pull Through
5 5 5 5 5 A A/P Release Carrier Pull Out
1 Step Upthrust Device / Level Device
1 Comb-step / Pallet Impact Device
1 Missing Step / Pallet Device
1 Handrail Safety System
1 Step / Skirt Performance Index / Submit Readout
1 Step / Skirt Clearance (Loaded Gap)
1 Skirt Obstruction Devices
1 50% Periodic Inspection Escalator
1 Moveable Cone Guards / Control Rope
1 Hand Hold Strength / Speed Test
1 Load Step Deflection