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Notes: Any item answered “No” indicated: no problem. Any item answered “Yes” indicates a potential problem and the inspector should
indicate a Condition Grade Level (CGL) by circling “2” or “3” in the column marked Yes/CGL. CGL 2 means component is
serviceable but some damage or deterioration was observed. CGL 3 means damage or deterioration was observed and requires further
evaluation. VI-1, VI-2, etc will usually identify the location; where VI-1 is indicated on attached drawing. Additional comments on
attached page; as necessary.
Page 1 of 3
FORM: PSM0011
MECHANICAL INTEGRITY INSPECTION FORM
S0 Other (explain) 2 3
S5 Fireproofing damage 2 3
E0 Other (explain) 2 3
E1 Loose connections 2 3
E2 No ground connections 2 3
E3 Conduit damage 2 3
N3 Flange Leaking 2 3
W0 Other (explain) 2 3
W1 Support damage 2 3
W2 Handrail deficiencies 2 3
W3 Stumbling hazards 2 3
Notes: Any item answered “No” indicated: no problem. Any item answered “Yes” indicates a potential problem and the inspector should
indicate a Condition Grade Level (CGL) by circling “2” or “3” in the column marked Yes/CGL. CGL 2 means component is
serviceable but some damage or deterioration was observed. CGL 3 means damage or deterioration was observed and requires further
evaluation. VI-1, VI-2, etc will usually identify the location; where VI-1 is indicated on attached drawing. Additional comments on
attached page; as necessary.
Page 2 of 3
FORM: PSM0011
MECHANICAL INTEGRITY INSPECTION FORM
I0 Other (explain) 2 3
I2 Insulation damage 2 3
Notes: Any item answered “No” indicated: no problem. Any item answered “Yes” indicates a potential problem and the inspector should
indicate a Condition Grade Level (CGL) by circling “2” or “3” in the column marked Yes/CGL. CGL 2 means component is
serviceable but some damage or deterioration was observed. CGL 3 means damage or deterioration was observed and requires further
evaluation. VI-1, VI-2, etc will usually identify the location; where VI-1 is indicated on attached drawing. Additional comments on
attached page; as necessary.
Page 3 of 3
FORM: PSM0011