Driver Print (Required) Technician Print (Required) Driver Signature (Required) Technician Signature (Required) I CERTIFY I HAVE INSPECTED THE EQUIPMENT LISTED ABOVE IN ACCORDANCE WITH 49 CFR 393 APPENDIX G. Pass Fail Inspection Facility Name Inspection Facility Address Site Number Customer Name Work Order Inspection Number Date Year Make Unit # License # / State Registered Owner Site Information Inspection Status Tractor DOT Inspection This Vehicle Inspection is in accordance with, and the following list of components are to be inspected per the criteria listed in 49 CFR Part 396.17 through 396.23 Appendix G to Subchapter B, Minimum Periodic Inspection Standards. Pass Fail √ = Inspected NA = Not Applicable 1 Brake System a. Operation, Adjustments, Leaks (Service & Parking Brakes) b. Friction Parts (Shoes, Linings, Drums, Rotors, etc…) c. Hoses, Tubing, etc… d. Low Pressure Warning Device e. Tractor Protection Valve(s) f. Air Compressor g. Electric Brakes h Hydraulic Brakes i Vacuum System j. Antilock Brake System k. Automatic Brake Adjusters 2 Coupling Devices a. Fifth Wheel, Saddle Mounts, etc… b. Pintle Hook c. Drawbar/Towbar Eye/Tongue d. Safety Devices 3 Exhaust System a. No part of the exhaust system of required by Part 393 shall be operable Pass Fail √ = Inspected NA = Not Applicable 6 Safe Loading a. Part(s) of vehicle or condition of b. Protection Against Shifting Cargo - Any vehicle without a front-end structure or equivalent device as required 7 Steering Mechanism a. Steering Wheel Free Play b. Steering Column c. Front Axle Beam & All Steering Components other than Steering Column other axle positioning part(s) cracked, broken, loose, or missing resulting in shifting of an axle from its normal position b. Spring Assembly c. Torque Radius or Tracking Components 9 Frame a. Frame Members b. Tire & Wheel Clearance c. Bumper, Mud Flaps & Brackets d. Adjustable Axle Assemblies (Sliding Subframe) Pass Fail √ = Inspected NA = Not Applicable 10 Tires a. Steer Tires b. All other tires c. Tires marked "Not for highway use" or otherwise marked and having like meaning d. Installation of speed restricted tires unless specifically designated by motor carrier 11 Wheels And Rims a. Lock or Side Ring b Wheels and Rims c Fasteners d. Welds Pass Fail √ = Inspected NA = Not Applicable 12 Windshield Glazing a. Requirements and exceptions as stated pertaining to any crack, discoloration or vision reducing matter (reference 393.60 for exceptions). loading such that the spare tire or any part of the load or dunnage can fall onto the roadway 4 Fuel System a. Visible Leak b. Fuel Tank Filler Cap Missing c. Fuel Tank Securely Attached 5 Lighting Devices a. All lighting devices and reflectors 14 Other b. Any exhaust system determined to be leaking at a point forward of or directly below the driver/sleeper compartment a. List any other condition(s) which may prevent safe operation of this vehicle 13 Windshield Wipers Any power unit that has an inoperative wiper, or missing or damaged parts that render it ineffective any motor vehicle shall be so located as would be likely to result in burning, charring, or damaging the electrical wiring, the fuel supply, or any combustible part of the motor vehicle DOTTCR1.2 c. Container securement devices on intermodal equipment d. Steering Gear Box e. Pitman Arm f. Power Steering g. Ball and Socket Joints h. Tie Rods and Drag Links i. Nuts j. Steering System 8 Suspension a. Any U-bolt(s), spring hanger(s), or EDWARD POOLEY LUIS HERRERARODRIGUEZ ✔ TRUCK TRACTOR TRAILER TA Atlanta Onsite 3181 Donald Lee Hollowell Parkway, Atlanta, GA 30318 406 3313 5/13/2019 GE1824 15 222362 Odometer TEMP / FL Tractor Information 3AKBCYCY6FDGE1824 VIN FTL TRUCK TRACTOR TRAILER ✔ ✔ ✔ ✔ N A ✔ ✔ ✔ ✔ ✔ N A N A ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ N A ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ N A ✔ ✔ ✔ ✔ ✔ ✔ 32nds 32nds Left Push Rod Travel Right Short Stroke Long Stroke In: In: In: Brake Thickness Chamber: Chamber: In: ✔ 24 24 1 1/4 1 1/4 1/2 1/2 17 17 Steer ✔ 32nds 32nds 32nds 32nds Left Push Rod Travel Right Short Stroke Long Stroke In: In: In: Brake Thickness Chamber: Chamber: In: ✔ 30 30 1 1/4 1 1/4 1/2 1/2 15 16 15 17 Front Drive ✔ page 1 of 1
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Tractor DOT Inspection Site Information Tractor Information Inspection … · 2019. 5. 13. · Inspection FacilityName Inspection FacilityAddress Site Number Customer Name Work Order
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I CERTIFY I HAVE INSPECTED THE EQUIPMENT LISTED ABOVE IN ACCORDANCE WITH 49 CFR 393 APPENDIX G.
Pass
FailInspection
Facility NameInspection
Facility Address
Site Number Customer Name
Work Order Inspection Number Date
Year Make
Unit # License # / State
RegisteredOwner
Site Information
Chamber:
Inspection StatusTractor DOT Inspection
This Vehicle Inspection is in accordance with, and the following list of components are to be inspected per the criteria listed in 49 CFR Part 396.17 through 396.23 Appendix G to Subchapter B, Minimum Periodic Inspection Standards.
Pa
ss
Fa
il
√ = Inspected
NA = Not Applicable
1 Brake System
a. Operation, Adjustments, Leaks (Service
& Parking Brakes)
b. Friction Parts (Shoes, Linings, Drums,
Rotors, etc…)
c. Hoses, Tubing, etc…
d. Low Pressure Warning Device
e. Tractor Protection Valve(s)
f. Air Compressor
g. Electric Brakes
h Hydraulic Brakes
i Vacuum System
j. Antilock Brake System
k. Automatic Brake Adjusters
2 Coupling Devices
a. Fifth Wheel, Saddle Mounts, etc…
b. Pintle Hook
c. Drawbar/Towbar Eye/Tongue
d. Safety Devices
3 Exhaust System
a. No part of the exhaust system of
required by Part 393 shall be operable
Pa
ss
Fa
il
√ = Inspected
NA = Not Applicable
6 Safe Loading
a. Part(s) of vehicle or condition of
b. Protection Against Shifting Cargo - Any
vehicle without a front-end structure
or equivalent device as required
7 Steering Mechanism
a. Steering Wheel Free Play
b. Steering Column
c. Front Axle Beam & All Steering
Components other than Steering
Column
other axle positioning part(s) cracked,
broken, loose, or missing resulting in
shifting of an axle from its normal
position
b. Spring Assembly
c. Torque Radius or Tracking Components
9 Frame
a. Frame Members
b. Tire & Wheel Clearance
c. Bumper, Mud Flaps & Brackets
d. Adjustable Axle Assemblies (Sliding
Subframe)
Pa
ss
Fa
il
√ = Inspected
NA = Not Applicable
10 Tires
a. Steer Tires
b. All other tires
c. Tires marked "Not for highway use" or
otherwise marked and having like
meaning
d. Installation of speed restricted tires
unless specifically designated by motor
carrier
11 Wheels And Rims
a. Lock or Side Ring
b Wheels and Rims
c Fasteners
d. Welds
Pa
ss
Fa
il
√ = Inspected
NA = Not Applicable
12 Windshield Glazing
a. Requirements and exceptions as stated
pertaining to any crack, discoloration
or vision reducing matter (reference
393.60 for exceptions).
loading such that the spare tire or any
part of the load or dunnage can fall
onto the roadway
4 Fuel System
a. Visible Leak
b. Fuel Tank Filler Cap Missing
c. Fuel Tank Securely Attached
5 Lighting Devices
a. All lighting devices and reflectors
14 Other
b. Any exhaust system determined to be leaking at a point forward of or directly below the driver/sleeper compartment
a. List any other condition(s) which may prevent safe operation of this vehicle
13 Windshield Wipers
Any power unit that has an inoperative
wiper, or missing or damaged parts
that render it ineffective
any motor vehicle shall be so located as
would be likely to result in burning,
charring, or damaging the electrical
wiring, the fuel supply, or any
combustible part of the motor vehicle
DOTTCR1.2
c. Container securement devices on
intermodal equipment
d. Steering Gear Box
e. Pitman Arm
f. Power Steering
g. Ball and Socket Joints
h. Tie Rods and Drag Links
i. Nuts
j. Steering System
8 Suspension
a. Any U-bolt(s), spring hanger(s), or
EDWARD POOLEY LUIS HERRERARODRIGUEZ
✔TRUCK TRACTOR TRAILER
TA Atlanta Onsite
3181 Donald Lee Hollowell Parkway, Atlanta, GA 30318
406
3313 5/13/2019
GE1824
15
222362Odometer
TEMP / FL
Tractor Information
3AKBCYCY6FDGE1824VIN
FTL
TRUCK TRACTOR TRAILER
✔
✔
✔
✔
N A
✔
✔
✔
✔
✔
N A
N A
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
N A
✔
✔
✔
✔
✔
✔
✔
✔
N A
✔
✔
✔
✔
✔
✔
32nds32nds 32nds 32nds
Left Push Rod Travel RightShort StrokeLong Stroke
In:
In:
In:
Brake Thickness
Chamber: Chamber:
In:
✔
24 24
1 1/41 1/4
1/21/2
17 17
Steer✔
32nds32nds 32nds 32nds
Left Push Rod Travel RightShort StrokeLong Stroke
In:
In:
In:
Brake Thickness
Chamber: Chamber:
In:
✔
30 30
1 1/41 1/4
1/21/2
15 16 15 17
Front Drive✔
page 1 of 1
FD 00204 Revised 7/19/10
US DOT/FMCSA FEDERAL MOTOR CARRIER SAFETY REGULATIONSPERIODIC INSPECTOR/BRAKE INSPECTOR QUALIFICATIONS 49 CFR PARTS 396.19 & 396.25
Federal Motor Carrier Regulations require motor carriers to ensure compliance with qualification of inspectors.
Understand the inspection criteria set forth in 49 CFR Parts 393 & 396, Appendix G to Subchapter B--Minimum Periodic InspectionStandards, and can identify defective components
Understand the brake service or inspection task to be accomplished and can perform that task
Be knowledgeable of and have mastered the methods, procedures, tools, and equipment used when performing an inspection or anassigned brake service or inspection task
Be capable of performing an inspection or assigned brake service or inspection by reason of experience, training, or both
Qualified Inspectors must meet one of the following criteria:
I. _____Have successfully completed an apprenticeship program sponsored by a state, a Canadian Province, a federal agency or a labor union, or a
training program approved by a State, Provincial, or Federal Agency, or has a certificate from a State or Canadian Province which qualifies the
person to perform the assigned brake service or inspection task or Commercial Vehicle Safety Inspection. Specify:
Program/Certificate Name_____________________________________________ Date Completed_____________________