MACHINERY & MECHANIZED EQUIPMENT CERTIFICATION FORM From vine Conmacwns —_UBMEK-BNVRDMEUTEL #22690 _ Gavetne: NOY P= te Cen ee oae eee SS conacs Tite: REPM® LIM WARE Naval Base oun “To: Contracting Officer ‘Sub: SAFETY CERTIFICATION OF MACHINERY AND MECHANIZED EQUIPMENT Reference(s) US. Army Comps of Eaginers, EM 2851-1 (15 Sep 208), Sey & Heath Requirements Mana ()NAVEAC P07 (Dee 2005) chiles no others ipectd by State ole found nsf perating condition an in comptince with ction form shal be valle fr insasion an he work sit > Subsequent re inspections wile conducted atest annually theresier Inspection and eeifeation of machinery and mechanized equipment, 2WTshas been made fr he following eee 2. Henifston of eipmest: (1) Make: SiMDOQOM Model: _ eqzed by EM 385.1 and NAVFACP ‘Liense’Serial Number: 0503001140 )Mate:_ Bishi a eae ene cease Naber: Yes 2, The above listed egupment is CERTIFIED TO BE IN SAFE OPERATING CONDITION BY A (QUALIFIED PERSON IN ACCORDANCE WITH THE MANUFACTURE'S RECOMMIENDATIONS. vary pason opening motor vehicles posses, tal ime whl operating sch cil, iene pernit ‘ali forthe equimentbeing operated. Al machinery sad mechaizel equipment wil ope als lente auld personnel "ceri that al machinery and mechanized equipment sordice wih te manufac’ recommecdason, bovis eid to beste pening conn a ‘Name Tite and signature of Qualified Perso ming the inspection Tile: _TREANSICL ND Pre: judew , 4 , 200 Copy: Cones Fie