Performance Work Statement Attachment III - Electric Elevator Test

5648325476250002349500
Fort Huachuca, Directorate of Public Works
Periodic tests of Electric Elevators
Quality Assurance Check List

Test Performed: Bi-Annual ☐ Annual ☐ Five (5) Year ☐
Test Performed: Bi-Annual ☐ Annual ☐ Five (5) Year ☐

Building & Unit Information
Building Name
Owner/Building Management Name
Building Address
Unit Identification / Unit PIN

BI-ANNUAL INSPECTIONS

ASME Section
Pass
Fail
N/A
Static and relief pressure test
1005.1

Safety test
1002.1

ANNUAL INSPECTIONS

ASME Section
Pass
Fail
N/A
Oil Buffers
8.11.2.2.1

Safeties
8.11.2.2.2

Governors
8.11.2.2.3

Slack-Rope Devices on Winding Drum Machines
8.11.2.2.4

Normal and Final Terminal Stopping Devices
8.11.2.2.5

Firefighters’ emergency Operation
8.11.2.2.6

Standby or emergency Power Operation
8.11.2.2.7

Power Operation of Door System
8.11.2.2.8

Broken Rope, Tape, or Chain Switch
8.11.2.2.9

E/E/PES Electrical Protective Devices
8.11.2.2.10

FIVE (5) YEAR INSPECTION

ASME Section
Pass
Fail
N/A
Car and Counterweight Safeties
8.11.2.3.1

Governors
8.11.2.3.2

Oil Buffers
8.11.2.3.3

Braking System
8.11.2.3.4

Emergency and Standby Power Operation
8.11.2.3.5

Emergency Terminal Stopping and Speed Limiting Devices
8.11.2.3.6

Power Opening of Doors
8.11.2.3.7

Leveling Zone and Leveling Speed
8.11.2.3.8

Inner Landing Zone
8.11.2.3.9

Emergency Stopping Distance
8.11.2.3.10

The Above Tests Were Performed In Compliance With ASME A17.1 Firm Performing Test/Service
Elevator Contractor Number

Firm Address
Firm City/State/Zip
Name of Mechanic Performing Test/Service
Date of Test/Service