Jan2015
Vermon
t Department of Public Safety
DIVISION OF FIRE SAFETY
Office of the State Fire Marshal, State Fi
re
Academy and State Haz-Mat T
e
a
m
HYDRAULIC ELEVATOR PERIODIC TEST FORM
General
Date:
VTEL#: # Stops:
Building Name:
Address:
Class:☐ Passenger
☐Freight
City:
Speed: Capacity:
Owner:
*Has been tested in accordance with the current Vermont Elevator Safety Rules*
And found to be:
☐ In Compliance ☐ NOT In Compliance
Comments: __________________________________________________________________________
Signed:________________________________________________________ Date:_________________
Vermont License #:________________ Employer: ___________________________________________
HYDRAULIC ELEVATORS
Working Pressure:_________psi Relief Pressure:_________psi ☐ Sealed
☐
No Load
☐
Full Load ______lbs
Reason for Test:
Hydraulic Elevators – Periodic Test Requirements – Category 1
Hydraulic Cylinders & Pressure Piping – Visual Examination or Leakage Test
☐Pass ☐Fail
Normal Terminal Stopping Devices – Tested
☐Pass ☐Fail
Firefighters Emergency Operation – Test ☐ N/A
☐Phase I ☐Phase II
Standby or Emergency Power ( Battery Lowering) – Test ☐ N/A ☐Pass ☐Fail
Power Operation of Door
System – Closing Forces and Speed (Front)
______lbs ______sec
Low Oil Protection – Test
☐Pass ☐Fail
☐ N/A
☐Pass ☐Fail
Hydraulic Elevators – Periodic Test Requirements – Category 5
Plunger Gripper (where provided) – Test
☐Pass ☐Fail
Overspeed Valves – Test – Full Load ☐ N/A ☐Pass ☐Fail
☐ Materials
Pressure Switch ☐ N/A ☐Pass ☐Fail
P
ower Operation of Door System – Closing Forces and Speed (Rear)
☐ N/A
*This form MUST be complete, signed, dated and posted in the machine room to be valid*
