<p> Denver Fire Department Fire Prevention Division</p><p>PO Box 40385 Denver, CO 80204 p: 720.913.3474 f: 720.913.3596 www.denvergov.org/fire Roped Hydraulic Elevator Safety Test Report Building Name: Manufacturer: Capacity: Facilit y/ Address: State Reg #: Job/Contract#: Gener al City: Install Date: Duty: Passenger Freight Infor matio Zip: Rated Speed: Freight Loading Class: C1 C2 C3 n Circle One 1 Acceptance Category 1 Tests 2 Category 1 and 5 Witnessed Testing Date Tests Performed: Was Inspector Present: Yes No If "Yes" Inspector Must Sign Test Report Piston Diameter: in Relief Valve to be set at 150% or less of Adjustment Needed: Yes No Relief No Load Working PSI: psi the Working Pressure Adjustments Sealed: Yes No Valve 1 Full Load Working PSI: psi Relief Valve Setting: psi Test Tag Installed: Yes No Mechanical and Visual Check of Governor Operation: Pass Fail Governor Tripping Speed: Pass Fail Safeti 2 es Speed at which Governor Tripped: fpm Car Safeties (rated load): Pass Fail /Gov Slack Rope Switch: NA Pass Fail Test Tag Installed: Yes No 2 Plunger Gripper Operational: NA Yes No 2 Overspeed Valve operational: NA Yes No Time Started: Proper Fuses Installed: Yes No Connections Tight: Yes No Powe Time Ended: Controller Clean: Yes No Jumpers Removed: Yes No r Down Elapsed Time: Relay(s) Visually Inspected: Yes No Static Change In Car Position: Yes No If "yes" Distance in Oil Loss Accounted For: Yes No Test NOTE: If any oil loss cannot be accounted for, the elevator must be removed from service and the Authority Having Jurisdiction must be notified. Stop Switches: In Car: Pass Fail Pit: Pass Fail Top Of Car: Pass Fail Safet y Directional Limits: Up: Pass Fail Down: Pass Fail Low Oil Protection: NA Pass Fail Devic es Final Limits: Up: Pass Fail Down: Pass Fail Escape Hatch Contact: NA Pass Fail Low Oil Pressure Switch: NA Pass Fail Car Door Restrictor: NA Pass Fail Closing Force (Max 30lbf): lbf Safety Edge: Pass Fail Door Guides Secure: Pass Fail Doors Closing Time: sec Electronic Edge: Pass Fail Door Interlocks/Gate Switch: Pass Fail</p><p>Emer Phase I Recall: NA Pass Fail Phase I Fire Service Instruction Signage In Place: Yes No gency Phase II Operation: NA Pass Fail Phase II Fire Service Instruction Signage In Place: Yes No Opera tion Emergency Communication: NA Pass Fail Alarm Bell: Pass Fail Emergency Lights: Pass Fail Standby or Emergency Power Operation: NA Pass Fail Logs Properly Maintained: Yes No Logs Updated with this Annual safety test: Yes No Logs Fire service logs maintained: Yes No I certify all statements are true to the best of my knowledge and that all testing was performed according to The Elevator and Escalator Certification Act CRS § 9-5.5, Conveyance Regulations 7 CCR 1101-8 and adopted Codes.</p><p>Mechanic Name: Company Name: Signa tures Signature: Date: StateLicense #: </p><p>Inspector Name: Company Name: </p><p>Signature: Date: State License #: 1 Required to be performed during acceptance inspections 2 Required to be performed during acceptance and Category 1 and 5 witnessed inspections</p><p>6/24/13</p>