Annual Periodic Vehicle Inspection Report
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3Annual Periodic Vehicle Inspection Report
Name and Address of Inspecting Company or Agency
Registered Owner’s Name
Date
Time
Street
Certified Inspector’s Name (Print or Type)
City, State, Zip Code
The signing of this inspection report certifies that the technician
meets and exceeds all requirements of 49 CFR §396.17 and
Motor Carrier Operating Vehicle (If different from Owner)
compatible state regulations and that the technician has the
necessary tools, and is skilled in completion of the annual
Street
inspection, as listed in 49 CFR §396.17
City, State, Zip Code
Technician’s Signature______________________________
License Plate Number/State
Vehicle Identification Number
Vehicle Make
Vehicle Model
Model Year
Vehicle Components Inspected
Need
Repair
Need
Repair
Need
Repair
OK
Item
OK
Item
OK
Item
Repair
Date
Repair
Date
Repair
Date
1. BRAKE SYSTEM
5. FUEL SYSTEM
10. SUSPENSION
Adjustment
Visible Leaks
Springs (
)
cracked/broken/shifted
Drums or Rotors
Fill Caps in place/intact
U-bolts. Hangers, etc.
Hoses and/or Tubing
Tank(s) securely attached
Torque, Radius, Tracking Arms
Lining
6. LIGHTING DEVICES
11. FRAME
Warning (Low Pressure)
Headlamps
Frame Members
Tractor Protection Valve
Front Turn Signals
Tire & Wheel Clearance
Air Compressor
Front ID/Clearance Lamps
Sliding Subframe (adj. axle)
Service Brakes
Side Marker Lamps – Left
12. TIRES
Parking Brakes
Side Marker Lamps -Right
Steering Axle Tires -Condition
Electric Brakes
Rear Turn Signals
Steering Tires - over 4/32” tread
Hydraulic Brakes
Stop Lamps
Other Tires – Condition
Vacuum Brakes
Tail Lamps
Other Tires – over 2/32” tread
Warning (Sys Failure)
Rear ID/Clearance Lamps
13. WHEELS & RIMS
Reflectors / Ref Tape
Lock/Slide Ring
2. STEERING SYSTEM
Free Play (Lash)
Fasteners
7. COUPLING DEVICES
Steering Column
5
Wheel
Disk/Spoke Condition
TH
Front Axle Beam
Pintle Hooks
Welds
Steering Gear Box
Drawbar Eye
List any other condition
which may affect safe
Pittman Arm
Drawbar Tongue
vehicle operation
Ball & Socket Joints
Safety Devices
Tie Rods & Drag Links
8. EXHAUST SYSTEM
Nuts, Bolts, Fasteners
Leaks
Power Steering Fluid
Placement
3. WINDSHIELDS
9. SAFE LOADING
Securement Devices
4. WIPERS
MARK COLUMNS AS FOLLOWS: x = OK; o = Needs repair; NA = Does not apply; Fill in Repair date as appropriate
I CERTIFY THE ANNUAL VEHICLE INSPECTION HAS BEEN DONE ACCURATELY AND COMPLETELY. I FURTHER
CERTIFY THAT THIS INSPECTION COMPLIES WITH THE REQUIREMENTS OF 49 CFR §396.21.
This information must be available on board the vehicle, either as a copy of this report, or on a decal that complies with 49
CFR §396.17(c)(2). This report must be kept a minimum of fourteen months from date of completion
Certified Inspector’s Signature:
Date:
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