VEHICLE SAFETY INSPECTION FORM please print legibly Full Name: ac Dat e : / ( Email: Phone: In spec tion Type (circle on e ): TNC D ecal#: Vehicl e Inform ation: VIN ff I l1 M ak e : 8 Model: ·3 3 ] Ye ar: 'AO l 1 # of Do ors Plat e Numb e r and Sta t e : _C _ u _ r r_e n _ t _ M _i_ l e _ a g e _( e _x a _c t ) , , O -R _ e g i _ s t _ e _ r e d _ O _ w _ n _ e _ r Gasoline Partner Driver's Signature X Vehicle Inspection Site: Vehicle Inspection Check List (Please note: All Inspections Must Show 100% to Pass) Inspection Items Pass Fail Inspection Items Bumpers (no sharp edges) Horn Windshield 0dometer/Speedomet Mirrors (Int/Ext/Rear View Headlights (high/lo Windshield Wipers/Defros �\�re \\ah+� All Passenger Windows Turn Indicators (Open/close properly, Tint light transmission > 24%) Brake/Back-up light Doors (open/close/lock) Muffler/Exhuast Driver Seat (A��fety Tires (min. 2/32" tre �hts� (Spare tire, tire jack, 1 Int. , ir bag handle/lugwrench or inflator/sea!er kit) pms, Etc.) R0�\; Emergency Brake All Seating Positions Foot Pedals (V\/orking Safety Belts) Foot Brakes (Stopping) Steering/ sus pension Overall Vehicle Inspection: (All vehicles that pass inspection are good for 1 Calendar Year) Inspector Name: Certification Number Pass Fail X Inspector Signature x _ Af¢ Comments: j V � - �\} U'