Send Original To
Department of Safety and Environmental Compliance
University of South Alabama
307 University Boulevard
CSAB 332
Mobile, Alabama 36688
(251) 460-7070 FAX (251) 460-7278
Elevators Annual Test Report of Governors,
Safety Devices, Oil Buffers Relief Valves and Firefighter Service
PLEASE PRINT OR TYPE
Location Name Date of Test Rated Speed
fpm
Address Rated Capacity
City State Zip Manufactured By
County Owner’s ID Material of Guide Rails Steel Wood
Circle Type of Elevator Circle Type of Power
PASSENGER FREIGHT SPECIAL SERVICE Electric (Drum/Traction) Electric (Wood Rails) Screw
CHAIR LIFT LULA Rack and Pinion Hydraulic-Direct
SIDE WALK LIFT DUMBWAITER HAND POWERED Rope and Sprocket Roped Hydraulic
VERTICAL WHEEL CHAIR LIFT INCLINED WHEEL CHAIR Other Describe:
OTHER Describe:
All tests are to be conducted as required in ASME A17.1-Part X. Additional explanation of each test component can be found in
the ASME A 17.2 Inspector’s Manual. Annual test of Type A, B C safeties are to be conducted without weight on the platform and
at reduced speed. Hydraulic relief valve tests are to be conducted by engaging the stop ring.
Complete this section for the Annual Test for Governors and Safeties
Date of last five year full loaded test . Circle Correct Response
Has the car safeties been visually inspected and operated? Yes No N/A
Has the counterweight safety been visually inspected and operated? Yes No N/A
Has the car governor been visually inspected and operated? Yes No N/A
Has the counterweight been visually inspected and operated? Yes No N/A
Was the governor tripped by hand to operate the safeties? Yes No N/A
Has the governor tripping speed been checked? Yes No N/A
Has the over speed switch tripping speed been check? Yes No N/A
Has the oil buffer plunger return time been checked? Yes No N/A
Have the car and counterweight oil buffers been tested by fully compressing the buffer? Yes No N/A
If the unit does not have a governor, was the safety and slack rope devices activated by Yes No N/A
obtaining the necessary slack rope?
Amount of cable leaving the safety drum for type B safeties inches. Number of turns remaining on the drum .
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Elevators Annual Test Report of Governors,
Safety Devices, Oil Buffers Relief Valves and Firefighter Service Complete this section for the Annual Test
for Hydraulic Units 15 Minutes Standing Test is Required
Has the control valve or hydraulic been changed since last safety test? Yes No
Full load working pressure is psi. The Full Load pressure is posted in the machine room . Yes No
The relief valve bypass pressure was tested at psi. The relief pressure was tested by engaging the stop ring. Yes No
Was there any changes in car position that cannot be accounted for by visible leakage or temperature change during the test? Yes No
Have the flexible hoses and fittings been tested for at least 30 seconds at the relief valve setting? Yes No N/A
Pressure switch settings psi. Has the pressure switch and related circuits been tested for operation? Yes No N/A
Complete this section for all safety devices.
Has the operation of the Up normal limit been checked? Yes No
Has the operation of the Down normal limit been checked? Yes No
Has the operation of the Up final limit been tested? Yes No
Has the operation of the Down final limit been tested? Yes No
Is the fire hall switch operational? Yes No
Have the power doors been tested? Yes No
Were the normal and terminal electrical stopping devices tested? Yes No N/A
Where provided, was the firefighter’s service inspected and tested? Yes No N/A
Where provided, was the standby emergency power inspected and tested? Yes No N/A
Where provided, was the broken rope, tape or chain switches tested? Yes No N/A
Where provided, were the closing forces of power operated hoistway door systems operated and tested? Yes No N/A
Does the elevator open with the elevator car level with the landing? Yes No
Is the oil level within the manufacturer’s recommended guidelines? Yes No
DID THE UNIT PASS ALL TESTING REQUIREMENTS PRIOR TO BEING RETURNED TO SERVICE YES NO
If no, state why the unit failed and contact our office as soon as possible.
THE UNIT MAY NOT BE RETURNED TO SERVICE IF ANY SAFETY DEVICE FAILED.
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Company conducting the test
Address Person conducting the test
City Phone Signature Date
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