Wheeler 118 - Mechanized Equipment Inspection Form

MACHINERY AND MECHANIZED EQUIPMENT/CRANE/ELEVATORS/HOISTS
Contractor
Subcontractor*
Contract No
Title
USACE
CERTIFICATION OF MACHINERY AND MECHANIZED EQUIPMENT
Reference: (a) U.S. Army Corps of Engineers Manual EM 385-1-1 General Safety Requirements

1. Inspection/certification of machinery and mechanized equipment, as required by Reference (a) has been made as shown below:

a. Identification of Equipment:
EQUIPMENT #1
Make*
Model*
Serial Number*
Inspection Date*

MonthDayYear
Date
EQUIPMENT #2
Make
Model
Serial Number
Inspection Date

MonthDayYear
Date
EQUIPMENT #3
Make
Model
Serial Number
Inspection Date

MonthDayYear
Date
EQUIPMENT #4
Make
Model
Serial Number
Inspection Date

MonthDayYear
Date
EQUIPMENT #5
Make
Model
Serial Number
Inspection Date

MonthDayYear
Date
EQUIPMENT #6
Make
Model
Serial Number
Inspection Date

MonthDayYear
Date
2. The above listed equipment is certified to be in safe operating condition as certified by a qualified individual as outlined in Reference (a

Name, title and signature of qualified individual making the inspection:
Name*
Title*
Firm
Signature

Clear
Should be Empty:

MACHINERY AND MECHANIZED EQUIPMENT/CRANE/ELEVATORS/HOISTS