Elevator 5 Year Safety Test Report
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1
2Department of Labor and Industries
ELEVATOR FIVE YEAR
Elevator Section
SAFETY TEST REPORT
PO Box 44480
Olympia WA 98504-4480
Phone: (360) 902-6130
FAX (360) 902-6132
Send originals to above address
File a separate report for each car and counterweight tested.
Car
or Counterweight
1. Building name
2. Building Address
3. Elevator Conv #
Owner ID
Type of Machine
4. Capacity
Speed
Rail type
5. Governor Type
Bail
Flyball
Centrifugal
Other
6. Condition of Governor
Jaw Type
Condition
7. Governor Data Plate
Trip Speed
Pull Through
Pull Out
8. Governor Rope
Type
Size
Condition
9. Governor Rope Cable Tag attached?
Yes
No
10. Governor Overspeed Switch?
Yes
No
11. S.O.S Switch?
Yes
No
Where located?
12. Governor Tension Frame condition
13. Releasing Carrier condition
14. Type of Safeties
A
B
C
15. Condition of Safeties & Actuating Rods
16. Buffer Type
Standard
Reduced Stroke
Other
Car
Cwt
17. Buffer Data Plate
Min Load
Max Load
Max speed
Car
Cwt
18. Buffer Switch
Yes
No
Buffer Oil Level
19. Run by
Car
Cwt
(dimension in inches)
20. Have all annual tests been completed?
Yes
No
Tags attached?
Yes
No
21. Length of governor rope movement for safety jaws to touch rail
Inches
F621-051-000 elevator five year safety test report 05-2006
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