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IB-085

CERTIFICATE OF EXAMINATION AND TEST OFFORKLIFT/STACKER/REACH/TSP TRUCK

Certificate No:
Job No:
Client Name & Address

Unit Information
Type of inspection & test performed:
Name of Maker And Address:

Model: Survey Requested by:

Maker S/No: Unladen Weight:

Owner Distinguishing No/Police Reg. No: Manufacturing Year:

Engine S/No:
Standard Fork/Attachment Length:

Equipment Description& Source of Power:

Height of lift: Load Centre(mm) Radius(mm) Height(mm)

Safe Working Load:

Proof Load Applied:

INSPECTION STATUS

Company Name& Date of previous inspection:

ASC Test Equipment No: ASC/EQ/

Date of inspection & test: ASC Test Method No: ASC/ITP/

Next inspection & test due on:u Standard Reference& Regulation:

Inspector Name: Authorized Name:

Inspector’s Signature: Authorized Signature:

This is to certify that the equipment described in this certificate was inspected and tested in accordance to the aforementioned standard and
found free of major defect and at the time of inspection the equipment is satisfactory for its intended use within the limits
specified herein and that all the particulars are correct.

This certificate is granted subject to the condition that is understood and agreed that nothing herein contained shall be deemed to relieve any designer, manufacturer, seller, supplier, repairer or
operator of any warranty,

ADMIRAL SAFETY CONSULTANTS, AL-GARHOUD, P.O.BOX 125218, DUBAI -UAE, TEL: 04-2899389, FAX: 04-2840557
Doc.No.ASC-FKL-C-52D(Rev.2)(12/05/2019)
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express or implied, and Admiral Safety Consultants liability shall be limited to the acts or omissions of its employees, agents and subcontractors. Under no circumstances whatsoever shall
Admiral Safety Consultants nor their
Engineer be liable for any injury or damage to any person or occurring by reason of negligent operation or any defect in materials, machinery, equipment or other items other than such defects
ascertainable by normally accepted
standards and only those items actually inspected by Admiral Safety Consultants and which are covered only by this certificate. Any person not a party to the contract pursuant to which this
document is delivered may not assert
claim against Admiral Safety Consultants for any liability arising out of errors or omissions which may be contained in said document and in connection with any activities for which it may
provide. This certificate shall not be
re produced except in full without the approval of Admiral Safety Consultants.

NOTE:
1. The certificate is valid for 12 months (in accordance with DAC-REQ-18) from the date of inspection.
2. Any alteration, dismantling, adjustment and repairs of the equipment will invalid this certificate.*
3. We kindly advice to implement corrective action on the items mentioned overleaf.
Certificate No:

COMPONENTS OK NG NA COMPONENTS OK NG NA

Equipment manufacturers instruction &operational Manual

Horn
&last test report/certificate details available

Operator documents Mirrors

Engine Brake Lights

Hydraulic system Head lights

Lifting Cylinders/slip Warning Lights

Tilting Cylinders/slip Reverse Lights
Lifting Chains Reverse Audible Alarm
Forks/Attachment Revolving Beacon
Steering Fire Extinguisher
Mast Rollers Load chart in cab
Counterweight General condition
Cab And Safety Equipment Maintenance
Tires Visual
Brakes Load Testing
Job No:
Ok-Meets requirement NA-Not applicable NG-No Good(Insert
number to identify comment on form)

REMARKS:
Item no. Comments

ADMIRAL SAFETY CONSULTANTS, AL-GARHOUD, P.O.BOX 125218, DUBAI -UAE, TEL: 04-2899389, FAX: 04-2840557
Doc.No.ASC-FKL-C-52D(Rev.2)(12/05/2019)
of 2 2 Page
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ADMIRAL SAFETY CONSULTANTS, AL-GARHOUD, P.O.BOX 125218, DUBAI -UAE, TEL: 04-2899389, FAX: 04-2840557
Doc.No.ASC-FKL-C-52D(Rev.2)(12/05/2019)
of 2 3 Page